Provider Demographics
NPI:1164466827
Name:CHURCH, LORI ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:ANN
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4877
Mailing Address - Country:US
Mailing Address - Phone:423-431-0509
Mailing Address - Fax:423-722-2060
Practice Address - Street 1:401 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4877
Practice Address - Country:US
Practice Address - Phone:423-929-2584
Practice Address - Fax:423-542-5109
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38090207Q00000X
OH35082925207Q00000X
NC200701334207Q00000X
TN47644207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDR0646OtherRAILROAD MEDICARE
NC023U2OtherBLUE CROSSS BLUE SHIELD OF NC
NC2071970BMedicare PIN