Basic Information
| Provider Information | |||||||||
| NPI: | 1346230257 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BELLA T PROSPERO MD SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1329 | ||||||||
| Address2: | |||||||||
| City: | MATTESON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604434329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087475850 | ||||||||
| FaxNumber: | 7087479991 | ||||||||
| Practice Location | |||||||||
| Address1: | 17901 GOVERNORS HWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HOMEWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604301144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087997193 | ||||||||
| FaxNumber: | 7087993839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | PROSPERO | ||||||||
| AuthorizedOfficialFirstName: | BELLA | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7087997193 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01635492 | 01 | BCBSIL GROUP NUMBER | OTHER |