Provider Demographics
NPI:1366467813
Name:CHRISTENSEN, PAUL MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MARK
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6003
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61126-6003
Mailing Address - Country:US
Mailing Address - Phone:815-398-3000
Mailing Address - Fax:815-391-5096
Practice Address - Street 1:444 ROXBURY ROAD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5059
Practice Address - Country:US
Practice Address - Phone:815-398-3000
Practice Address - Fax:815-398-3041
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3605671207RI0011X, 207UN0901X, 207RC0000X, 2085B0100X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101 15504OtherB/C B/S OF ILLINOIS
GACB0709/060009207OtherRR MEDICARE GROUP ID/ PIN
IL036056751 1Medicaid
IL036056751 3Medicaid
IL101 15504OtherB/C B/S OF ILLINOIS
GACB0709/060009207OtherRR MEDICARE GROUP ID/ PIN
IL101 15504OtherB/C B/S OF ILLINOIS
ILC45932Medicare UPIN
ILP01873Medicare PIN