Basic Information
| Provider Information | |||||||||
| NPI: | 1811125966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ILIC | ||||||||
| FirstName: | CHRISTA | ||||||||
| MiddleName: | LYNN JILLARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15849 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314162549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123546303 | ||||||||
| FaxNumber: | 9123558655 | ||||||||
| Practice Location | |||||||||
| Address1: | 4548 EMPIRE CT | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224081939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403732244 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2009 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2014-01282 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | LL31863 | SC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 074475 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 0101276215 | VA | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.