Provider Demographics
NPI:1043280811
Name:NIELSEN, CHRISTOPHER M (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5666 EAST STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2425
Mailing Address - Country:US
Mailing Address - Phone:815-226-2000
Mailing Address - Fax:608-826-2710
Practice Address - Street 1:5666 EAST STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2425
Practice Address - Country:US
Practice Address - Phone:815-226-2000
Practice Address - Fax:608-826-2710
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44558207P00000X
IL036-126617207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34253900Medicaid
IL$$$$$$$$$Medicaid
IL801200004Medicare PIN
WI34253900Medicaid
IL$$$$$$$$$Medicaid