MEDICARE: SOUTHSIDE FAMILY MEDICINE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	336.073573	IL

General Provider Information

NPI Number	:	1922361450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE FAMILY MEDICINE PC

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

Provider Business Practice Location Address
First Line	:	1525 E 55TH ST
Second Line	:	SUITE 307
City	:	CHICAGO
State	:	IL
Zip	:	60615-5512
Country	:	US
Telephone Number	:	773-667-5577
Fax Number	:	773-667-9977

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CARLOS J. CRUDUP
Credential	:	MD
Telephone Number	:	773-667-5577

Provider Enumeration Date	:	06/19/2012
Last Update Date	:	06/19/2012

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