Basic Information
| Provider Information | |||||||||
| NPI: | 1023202769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTIE | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KINGS HWY S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859224496 | ||||||||
| FaxNumber: | 5859224442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 PORTLAND AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859224496 | ||||||||
| FaxNumber: | 5859224442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 4267 | IA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MB08459100 | NJ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VX0201X | 309706 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 60043860 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 6642533/9141242 | 01 | NJ | AETNA | OTHER | P3944345 | 01 | NJ | OXFORD HEALTH PLAN | OTHER | 60043861 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 010046653 | 01 | NJ | AMERICHOICE | OTHER | 2141547 | 01 | NJ | CIGNA | OTHER | 0175889 | 05 | NJ | MEDICAID |