Provider Demographics
NPI:1932163623
Name:STELLA, DOMINICK J (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINICK
Middle Name:J
Last Name:STELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13011 S 104TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1508
Mailing Address - Country:US
Mailing Address - Phone:708-478-3600
Mailing Address - Fax:708-478-3552
Practice Address - Street 1:13011 S 104TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1508
Practice Address - Country:US
Practice Address - Phone:708-274-3278
Practice Address - Fax:708-274-3299
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095778207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095778Medicaid
IL01621208OtherBLUECROSS BLUE SHIELD
IL236551OtherMEDICARE GROUP
ILCD8033OtherRAILROAD MEDICARE GROUP PTAN NUMBER
IL060069036OtherRAILROAD MEDICARE COOK
IL1508810086OtherHEART CARE CENTERS OF ILLINOIS GROUP NPI
IL236550OtherMEDICARE GROUP
ILCG1672OtherRAILROAD MEDIARE GROUP PTAN NUMBER
ILP00311979OtherRAILROAD MEDICARE KANKAKE
IL416810OtherMEDICARE GROUP
ILL92237Medicare ID - Type Unspecified
ILCD8033OtherRAILROAD MEDICARE GROUP PTAN NUMBER
ILP00311979OtherRAILROAD MEDICARE KANKAKE
IL416810OtherMEDICARE GROUP