Healthcare Provider Details

I. General information

NPI: 1992746309
Provider Name (Legal Business Name): CRESTWOOD MEDICAL ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13117 RIVERCREST DR
CRESTWOOD IL
60418-4419
US

IV. Provider business mailing address

13117 RIVERCREST DR
CRESTWOOD IL
60418-4419
US

V. Phone/Fax

Practice location:
  • Phone: 708-371-1190
  • Fax: 708-448-8812
Mailing address:
  • Phone: 708-371-1190
  • Fax: 708-448-8812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTONIO NORIEGA
Title or Position: PRESIDENT
Credential: MD
Phone: 708-371-1190