MEDICARE: DR. SAMUEL LEROY CHURCH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	048990	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	930122977	OTHER	GA	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	002342	OTHER	GA	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053398149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL LEROY CHURCH MD

Provider Business Mailing Address
First Line	:	PO BOX 1217
Second Line	:
City	:	HIAWASSEE
State	:	GA
Zip	:	30546-1217
Country	:	US
Telephone Number	:	706-896-0505
Fax Number	:	866-796-2502

Provider Business Practice Location Address
First Line	:	85 SEASONS LANE
Second Line	:
City	:	HIAWASSEE
State	:	GA
Zip	:	30546-3217
Country	:	US
Telephone Number	:	706-896-0505
Fax Number	:	866-796-2502

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	03/05/2014

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