Provider Demographics
NPI:1518275635
Name:CRUDUP, SAMARA (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMARA
Middle Name:
Last Name:CRUDUP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4264
Mailing Address - Country:US
Mailing Address - Phone:312-635-0973
Mailing Address - Fax:813-290-9691
Practice Address - Street 1:1446 E 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-2948
Practice Address - Country:US
Practice Address - Phone:773-369-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.124522208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036124522OtherLICENSE NO
IL036124522Medicaid
ILP01201664OtherRR MEDICARE
ILIL4144011,5011Medicare PIN