MEDICARE: DR. ANN ALLISA 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	207N00000X	Dermatology Physician	ME97605	FL
2	207ND0900X	Dermatopathology Physician	ME97605	FL

General Provider Information

NPI Number	:	1205905486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANN ALLISA CHURCH MD

Provider Business Mailing Address
First Line	:	14275 MIDWAY RD STE 400
Second Line	:
City	:	ADDISON
State	:	TX
Zip	:	75001-3661
Country	:	US
Telephone Number	:	866-697-8378
Fax Number	:	610-271-4245

Provider Business Practice Location Address
First Line	:	132 DUNDEE PL
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-8223
Country	:	US
Telephone Number	:	800-330-6770
Fax Number	:	954-633-3217

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	01/29/2024

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