Healthcare Provider Details

I. General information

NPI: 1104341163
Provider Name (Legal Business Name): CRESTWOOD ASSOCIATED MEDICAL CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13705 CICERO AVE
CRESTWOOD IL
60418-1824
US

IV. Provider business mailing address

13705 S. CICERO AVE.
CRESTWOOD IL
60445
US

V. Phone/Fax

Practice location:
  • Phone: 708-385-4416
  • Fax: 708-388-8825
Mailing address:
  • Phone: 708-385-4416
  • Fax: 708-388-8825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038010310
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number036039801
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number070.005243
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.103914
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN WILLIAM REVELLO
Title or Position: PRESIDENT
Credential: D.C.
Phone: 708-385-4416