Provider Demographics
NPI:1083661797
Name:GEMA
Entity Type:Organization
Organization Name:GEMA
Other - Org Name:BALLERT ORTHOPEDIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSEMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZARDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-2445
Mailing Address - Street 1:2434 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4113
Mailing Address - Country:US
Mailing Address - Phone:773-878-2445
Mailing Address - Fax:773-508-6699
Practice Address - Street 1:2434 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4113
Practice Address - Country:US
Practice Address - Phone:773-878-2445
Practice Address - Fax:773-508-6699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL0372370001Medicare ID - Type Unspecified2434 W. PETERSON AVE.