Provider Demographics
NPI:1295805778
Name:GELBORT, MICHAEL M (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:GELBORT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-0437
Mailing Address - Country:US
Mailing Address - Phone:815-230-2262
Mailing Address - Fax:815-230-2444
Practice Address - Street 1:2714 CATON FARM RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1309
Practice Address - Country:US
Practice Address - Phone:815-230-2262
Practice Address - Fax:815-230-2444
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL07100400103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00057668OtherRAILROAD MEDICARE
IL9904511OtherBLUE CROSS BLUE SHIELD
ILP00057668OtherRAILROAD MEDICARE
ILK23369Medicare UPIN