Healthcare Provider Details

I. General information

NPI: 1326236563
Provider Name (Legal Business Name): CHRISTINA MARIE CRUM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W STATE ST
ROCKFORD IL
61102-2112
US

IV. Provider business mailing address

1200 W STATE ST
ROCKFORD IL
61102-2112
US

V. Phone/Fax

Practice location:
  • Phone: 815-490-1600
  • Fax: 815-490-1625
Mailing address:
  • Phone: 815-490-1600
  • Fax: 815-490-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0085003094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: