Provider Demographics
NPI: | 1477529949 |
---|---|
Name: | PORCELLI, ROSALIA (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | ROSALIA |
Middle Name: | |
Last Name: | PORCELLI |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | ROSALIA |
Other - Middle Name: | |
Other - Last Name: | STARECHESKI |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 9977 WOODS DR STE 100 |
Mailing Address - Street 2: | |
Mailing Address - City: | SKOKIE |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60077-1057 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 224-364-2273 |
Mailing Address - Fax: | 847-663-8290 |
Practice Address - Street 1: | 9977 WOODS DR STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | SKOKIE |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60077-1057 |
Practice Address - Country: | US |
Practice Address - Phone: | 224-364-2273 |
Practice Address - Fax: | 847-663-8290 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-02-24 |
Last Update Date: | 2022-05-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 36097646 | 208000000X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 36097646 | Medicaid | |
IL | 578010 | Medicare ID - Type Unspecified | |
H21954 | Medicare UPIN |