Healthcare Provider Details

I. General information

NPI: 1124380563
Provider Name (Legal Business Name): MEGAN M CHURCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

133 OLD ROAD TO 9 ACRE COR
CONCORD MA
01742-4159
US

V. Phone/Fax

Practice location:
  • Phone: 774-442-2853
  • Fax: 774-443-7042
Mailing address:
  • Phone: 978-369-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number262615
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: