Healthcare Provider Details

I. General information

NPI: 1699775916
Provider Name (Legal Business Name): BELLA T PROSPERO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17901 GOVERNORS HWY SUITE 101
HOMEWOOD IL
60430-1144
US

IV. Provider business mailing address

PO BOX 1119
MATTESON IL
60443-4119
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-7193
  • Fax: 708-799-3839
Mailing address:
  • Phone: 708-747-5850
  • Fax: 708-747-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036058672
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: