Basic Information
| Provider Information | |||||||||
| NPI: | 1396997391 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTIE CLINIC PATHOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173661200 | ||||||||
| FaxNumber: | 2173666106 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173661200 | ||||||||
| FaxNumber: | 2173666106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2173661270 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHRISTIE BUSINESS HOLDING COMPANY INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.