Provider Demographics
NPI:1922361450
Name:SOUTHSIDE FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:SOUTHSIDE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRUDUP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-667-5577
Mailing Address - Street 1:1446 E 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-2948
Mailing Address - Country:US
Mailing Address - Phone:773-230-2741
Mailing Address - Fax:
Practice Address - Street 1:1525 E 55TH ST
Practice Address - Street 2:SUITE 307
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5512
Practice Address - Country:US
Practice Address - Phone:773-667-5577
Practice Address - Fax:773-667-9977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336.073573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty