Provider Demographics
NPI:1720151152
Name:GEBERT, RALPH JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:JOHN
Last Name:GEBERT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 W PETERSON AVE
Mailing Address - Street 2:STE 401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:773-588-3090
Mailing Address - Fax:773-588-3210
Practice Address - Street 1:3500 W PETERSON AVE
Practice Address - Street 2:STE 401
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659
Practice Address - Country:US
Practice Address - Phone:773-588-3090
Practice Address - Fax:773-588-3210
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410026724OtherRAILROAD MEDICARE
IL0001604768OtherBLUE CROSS BLUE SHIELD
P01107052OtherRAILROAD MEDICARE
IL0460007094Medicaid
ILL99903Medicare PIN
IL0460007094Medicaid
ILL99899Medicare PIN
IL7060007Medicare PIN
ILL99901Medicare PIN
IL7059007Medicare PIN
IL0001604768OtherBLUE CROSS BLUE SHIELD
0839990001Medicare NSC
IL7058007Medicare PIN
410026724OtherRAILROAD MEDICARE