1922361450 NPI number — SOUTHSIDE FAMILY MEDICINE PC

Table of content: (NPI 1922361450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922361450 NPI number — SOUTHSIDE FAMILY MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE FAMILY MEDICINE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922361450
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1446 E 63RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60637-2948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-230-2741
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1525 E 55TH ST
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60615-5512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-667-5577
Provider Business Practice Location Address Fax Number:
773-667-9977
Provider Enumeration Date:
06/19/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CRUDUP
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-667-5577

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  336.073573 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)