Provider Demographics
NPI:1699775916
Name:PROSPERO, BELLA T (MD)
Entity type:Individual
Prefix:DR
First Name:BELLA
Middle Name:T
Last Name:PROSPERO
Suffix:
Gender:F
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:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-4119
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058672207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036058672Medicaid
01635492OtherBCBSIL GROUP NUMBER
01635492OtherBCBSIL GROUP NUMBER
ILP00271087Medicare PIN
ILC44815Medicare UPIN
IL036058672Medicaid
IL212270Medicare PIN