Basic Information
| Provider Information | |||||||||
| NPI: | 1518275635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUDUP | ||||||||
| FirstName: | SAMARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 N MICHIGAN AVE | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126350973 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Practice Location | |||||||||
| Address1: | 1446 E 63RD ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606372948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7733696222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2010 | ||||||||
| LastUpdateDate: | 10/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 036.124522 | IL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 036124522 | 01 | IL | LICENSE NO | OTHER | 036124522 | 05 | IL | MEDICAID | P01201664 | 01 | IL | RR MEDICARE | OTHER |