Healthcare Provider Details

I. General information

NPI: 1821594565
Provider Name (Legal Business Name): CHARLES D BELL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 02/01/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 SOUTH MARTIN LUTHER KING DRIVE
CHICAGO IL
60616
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-0018
US

V. Phone/Fax

Practice location:
  • Phone: 312-842-7117
  • Fax: 312-326-2102
Mailing address:
  • Phone: 847-390-5900
  • Fax: 847-390-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036-162214
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number238740
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: