Provider Demographics
NPI:1104042597
Name:ANNIS, CHRISTY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTY
Middle Name:LYNN
Last Name:ANNIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:CHRISTY
Other - Middle Name:LYNN
Other - Last Name:HAUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5215 HOLY CROSS PKWY
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1469
Mailing Address - Country:US
Mailing Address - Phone:574-335-5000
Mailing Address - Fax:
Practice Address - Street 1:5215 HOLY CROSS PKWY
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-335-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.125342207P00000X
OH57.012518207P00000X
IN01069919207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000724321OtherANTHEM
IN201028090Medicaid
INP00967673OtherRR MEDICARE
INP00967673OtherRR MEDICARE
INM400052333Medicare PIN