Provider Demographics
NPI:1346230257
Name:BELLA T PROSPERO MD SC
Entity Type:Organization
Organization Name:BELLA T PROSPERO MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BELLA
Authorized Official - Middle Name:T
Authorized Official - Last Name:PROSPERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-799-7193
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4329
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:17901 GOVERNORS HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1144
Practice Address - Country:US
Practice Address - Phone:708-799-7193
Practice Address - Fax:708-799-3839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01635492OtherBCBSIL GROUP NUMBER
=========OtherEIN
01635492OtherBCBSIL GROUP NUMBER
ILDE0908Medicare PIN