Healthcare Provider Details

I. General information

NPI: 1811125966
Provider Name (Legal Business Name): CHRISTA LYNN JILLARD ILIC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2009
Last Update Date: 10/11/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4548 EMPIRE CT
FREDERICKSBURG VA
22408-1939
US

IV. Provider business mailing address

PO BOX 15849
SAVANNAH GA
31416-2549
US

V. Phone/Fax

Practice location:
  • Phone: 540-373-2244
  • Fax:
Mailing address:
  • Phone: 912-354-6303
  • Fax: 912-355-8655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2014-01282
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL31863
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number074475
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101276215
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: