Provider Demographics
NPI:1679576029
Name:GERSHBERG, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GERSHBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6840 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3441
Mailing Address - Country:US
Mailing Address - Phone:708-484-0042
Mailing Address - Fax:708-749-5489
Practice Address - Street 1:6840 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3441
Practice Address - Country:US
Practice Address - Phone:708-484-0042
Practice Address - Fax:708-749-5489
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103403Medicaid
ILH36026Medicare UPIN
ILL85679Medicare ID - Type Unspecified