Provider Demographics
NPI:1871523829
Name:CHRISTIE CLINIC, PLLC
Entity type:Organization
Organization Name:CHRISTIE CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGREGOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-366-1255
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-1200
Mailing Address - Fax:217-366-6106
Practice Address - Street 1:101 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3909
Practice Address - Country:US
Practice Address - Phone:217-366-1200
Practice Address - Fax:217-366-6106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207Q00000X, 207R00000X, 207V00000X, 261QM1300X, 207Q00000X
IL160003518225100000X
IL070006853225100000X
IL209005764363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL574790Medicare ID - Type UnspecifiedCLIA DERMATOLOGY DEPT
IL279504Medicare ID - Type UnspecifiedCLIA RANTOUL SATELLITE
IL434110Medicare ID - Type UnspecifiedPHYSICIAN ASSISTANTS
IL0407950001Medicare NSC
IL205364Medicare ID - Type UnspecifiedPHYSICAL THERAPY
IL279502Medicare ID - Type UnspecifiedCLIA UROLOGY DEPT
IL909010Medicare ID - Type UnspecifiedPODIATRY
IL623640Medicare ID - Type UnspecifiedESCOBAR
IL279500Medicare ID - Type UnspecifiedMAIN GROUP
IL433990Medicare ID - Type UnspecifiedNURSE PRACTICTIONERS
IL478230Medicare ID - Type UnspecifiedDDS-BIANCO