CRESTWOOD ASSOCIATED MEDICAL CENTER LTD (NPI# 1104341163) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1104341163 |
| Entity Type | Organization |
| Organization Name | CRESTWOOD ASSOCIATED MEDICAL CENTER LTD |
| Practice Address |
13705 Cicero Ave Crestwood IL 60418-1824 |
| Mailing Address |
13705 S. Cicero Ave. Crestwood IL 60445 |
| Practice Telephone | (708) 385-4416 |
| Practice Fax Number | 7083888825 |
| Mailing Telephone | 7083854416 |
| Mailing Fax Number | 7083888825 |
| Enumeration Date | 2017-08-10 |
| Last Update Date | 2017-08-10 |
| Authorized Official Name | DR. JOHN WILLIAM REVELLO (PRESIDENT) |
| Authorized Official Telephone | 7083854416 |
| Authorized Official Credential | D.C. |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 111N00000X | Chiropractor | 038010310 | IL | Chiropractic Providers |
| N | 207X00000X | Orthopaedic Surgery | 036039801 | IL | Allopathic & Osteopathic Physicians |
| N | 261QP2000X |
Clinic/Center Specialization: Physical Therapy |
070.005243 | IL | Ambulatory Health Care Facilities |
| Y | 207Q00000X | Family Medicine | 036.103914 | IL | Allopathic & Osteopathic Physicians |
| Street Address |
13705 CICERO AVE |
| City | CRESTWOOD |
| State | IL |
| Zip Code | 60418-1824 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1083136477 | Ashley Sage | Behavioral Analyst | 13430 West Circle Drive, Unit 209, Crestwood, IL 60418 | 2017-07-07 |
| 1497847255 | Ebony Nicole Johnson | Family Medicine | 4742 Cal Sag Rd, Crestwood, IL 60418 | 2006-09-29 |
| 1215372404 | Malak Elsheikh | Internal Medicine | 13755 Cicero Ave, Crestwood, IL 60418 | 2013-05-02 |
| 1356591549 | Luciano Fochesatto Filho | Internal Medicine | 13755 Cicero Ave, Crestwood, IL 60418 | 2008-09-24 |
| 1538603329 | Megan Kateri Valesey | Behavioral Analyst | 12745 Central Ave, Crestwood, IL 60418-1130 | 2016-12-13 |
| 1720581143 | Manjhoni Edmondson | Counselor | 5305 Pleasant Ln, Crestwood, IL 60418-1159 | 2018-03-12 |
| 1194228429 | Illinois Supreme Health Organization | Community/Behavioral Health | 5305 Pleasant Ln, Crestwood, IL 60418-1159 | 2018-03-13 |
| 1962974782 | Chloe Haberkorn | Optometrist | 5247 131st St, Crestwood, IL 60418-1255 | 2018-12-18 |
| 1265060396 | Kaitlin Marie Featherstone | Student in an Organized Health Care Education/Training Program | 13217 E Playfield Dr, Crestwood, IL 60418-1303 | 2020-04-01 |
| 1982256632 | Laureate Crestwood Operations LLC | Skilled Nursing Facility | 13301 Central Ave, Crestwood, IL 60418-1370 | 2019-07-12 |
| Find all providers in zip 60418 | ||||
| Taxonomy Code | 207Q00000X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Family Medicine |
| Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. |
| Notes: Source: American Board of Family Medicine [1/1/2007: changed title; 7/1/2007: added definition, added source; 7/1/2017: modified definition] - Note: The American Osteopathic Board of Family Physicians certification includes extensive use of Osteopathic Manipulative Treatment (OMT), which integrates the biological, clinical, and behavioral sciences. - Additional Resources: American Board of Family Medicine, www.theabfm.org. American Osteopathic Board of Family Physicians, www.osteopathic.org/certification - Board certification for Medical Doctors (MDs) is provided by the American Board of Family Medicine. Board certification for Doctors of Osteopathy (DOs) is provided by the American Osteopathic Board of Family Physicians or the American Board of Family Medicine. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1457693954 | Jianxia Wang | Family Medicine | 6411 Veterans Memorial Pkwy, Crestwood, KY 40014-8698 | 2013-03-22 |
| 1306103205 | Milum Wound Care Psc | Family Medicine | 3114 Setting Sun Ct, Crestwood, KY 40014-8409 | 2012-04-16 |
| 1215074026 | Midwest Physician Group Ltd | Family Medicine | 13811 Cicero Ave, Crestwood, IL 60445-1826 | 2007-01-31 |
| 1497847255 | Ebony Nicole Johnson | Family Medicine | 4742 Cal Sag Rd, Crestwood, IL 60418 | 2006-09-29 |
| 1427063379 | Crestwood Family Medicine | Family Medicine | 6106 Crestwood Sta Ste A, Crestwood, KY 40014-9473 | 2006-07-29 |
| 1174541510 | Donna Gatewood | Family Medicine | 6580 Kenwood Crossing Road, Crestwood, KY 40014 | 2006-07-17 |
| 1639102585 | Richard A Hefner | Family Medicine | 6580 Kenwood Crossings Road, Crestwood, KY 40014 | 2006-07-07 |
| 1992746309 | Crestwood Medical Associates Ltd | Family Medicine | 13117 Rivercrest Dr, Crestwood, IL 60418-4419 | 2006-06-08 |
| 1629034574 | Renee V Girdler | Family Medicine | 6411 Veterans Memorial Parkway, Crestwood, KY 40014 | 2006-04-20 |
| 1619968013 | Michael Ames Punnett | Family Medicine | 6580 Kenwood Crossing Rd, Crestwood, KY 40014-7614 | 2005-11-03 |
| Find all providers in CRESTWOOD | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.