MEDICARE: THOMAS C. CHURCH M.D., PA

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	207W00000X	Ophthalmology Physician	ME0016848	FL

General Provider Information

NPI Number	:	1114948387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS C. CHURCH M.D., PA

Provider Business Mailing Address
First Line	:	51 YACHT CLUB DR NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4473
Country	:	US
Telephone Number	:	850-244-1157
Fax Number	:

Provider Business Practice Location Address
First Line	:	51 YACHT CLUB DR NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4473
Country	:	US
Telephone Number	:	850-244-1157
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	THOMAS CHURCH
Credential	:
Telephone Number	:	850-244-1157

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	04/12/2010

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