Basic Information
Provider Information | |||||||||
NPI: | 1679733372 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BELLO KOTTENSTETTE | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 ERIE CT STE 4110 | ||||||||
Address2: | WEST SUBURBAN MEDICAL CENTER | ||||||||
City: | OAK PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 603022566 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7087632369 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 14 LAKE ST | ||||||||
Address2: | PCC LAKE STREET FAMILY HEALTH CENTER | ||||||||
City: | OAK PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 603022606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7083830113 | ||||||||
FaxNumber: | 7083839911 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2008 | ||||||||
LastUpdateDate: | 04/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 125054977 | IL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.