Individual
MR. CHRISTOPHER GLEN ILACQUA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
100 SOUTH ST, SOUTHBRIDGE, MA 01550-4051
(508) 909-8590
(508) 909-8589
Mailing address
PO BOX 415348, BOSTON, MA 02241-5348
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
Primary
1017464
MA
208100000X
Physical Medicine & Rehabilitation Physician
MD467051
PA
2255A2300X
Athletic Trainer
2015
MA
Other
Enumeration date
08/29/2009
Last updated
04/15/2024
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