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General NPI Number Information
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NPI Number | 1104341163
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Entity Type | Organization
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Legal Business Name | CRESTWOOD ASSOCIATED MEDICAL CENTER LTD
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Dates
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Enumeration Date | 08/10/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 13705 CICERO AVE
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City | CRESTWOOD
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State | IL
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Zip | 60418-1824
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Country | US
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Telephone | 708-385-4416
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Fax | 708-388-8825
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Provider Business Mailing Address
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Address Line | 13705 S. CICERO AVE.
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City | CRESTWOOD
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State | IL
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Zip | 60445
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Country | US
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Telephone | 708-385-4416
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Fax | 708-388-8825
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN WILLIAM REVELLO
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Credential | D.C.
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Telephone | 708-385-4416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 038010310
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 036039801
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 070.005243
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036.103914
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License Number State | IL
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