Organization
CREST CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. OBIDIKE AUGUSTINE NWAKUDU MD (PRESIDENT)
(708) 323-7608
Entity
Organization
Contact information
Practice address
2219 W TAYLOR ST, CHICAGO, IL 60612-4424
(708) 323-7608
(708) 286-6461
Mailing address
2219 W TAYLOR ST, CHICAGO, IL 60612-4424
(708) 323-7608
(708) 286-6461
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036116618
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036116618
—
IL
Enumeration date
11/19/2009
Last updated
11/26/2014
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