Healthcare Provider Details

I. General information

NPI: 1548261449
Provider Name (Legal Business Name): SHOSHANA B CHURCH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BARBARA W CHURCH PA

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 SOUTH DIVISION STREET
CARTERVILLE IL
62918-1539
US

IV. Provider business mailing address

P O BOX 577 109 CALIFORNIA
CARTERVILLE IL
62918-0577
US

V. Phone/Fax

Practice location:
  • Phone: 618-985-4841
  • Fax: 618-985-8101
Mailing address:
  • Phone: 618-985-8221
  • Fax: 618-985-4635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002122
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: