Basic Information
| Provider Information | |||||||||
| NPI: | 1720151152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEBERT | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 W PETERSON AVE | ||||||||
| Address2: | STE 401 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735883090 | ||||||||
| FaxNumber: | 7735883210 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 W PETERSON AVE | ||||||||
| Address2: | STE 401 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735883090 | ||||||||
| FaxNumber: | 7735883210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046007094 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 410026724 | 01 | RAILROAD MEDICARE | OTHER | 0001604768 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | P01107052 | 01 | RAILROAD MEDICARE | OTHER | 0460007094 | 05 | IL | MEDICAID |