Provider Demographics
NPI:1184836561
Name:OLIPHANT, CHRISTY A
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:A
Last Name:OLIPHANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 N EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4868
Mailing Address - Country:US
Mailing Address - Phone:309-692-1030
Mailing Address - Fax:309-691-3241
Practice Address - Street 1:5101 N EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4868
Practice Address - Country:US
Practice Address - Phone:309-692-1030
Practice Address - Fax:309-691-3241
Is Sole Proprietor?:No
Enumeration Date:2007-05-05
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
K38821Medicare PIN
IL809840Medicare ID - Type UnspecifiedGROUP #