Basic Information
| Provider Information | |||||||||
| NPI: | 1760692917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEVILLIER | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 FIFTH STREET, NORTH | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622442960 | ||||||||
| FaxNumber: | 6622442917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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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 | 208000000X | 20660 | MS | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 20660 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03936014 | 05 | MS | MEDICAID |