Provider Demographics
NPI:1235231226
Name:CHURCHVILLE, LAWRENCE A III (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:A
Last Name:CHURCHVILLE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TOWNSEND
Mailing Address - State:MA
Mailing Address - Zip Code:01469-1096
Mailing Address - Country:US
Mailing Address - Phone:978-597-2327
Mailing Address - Fax:978-597-8593
Practice Address - Street 1:208 MAIN ST
Practice Address - Street 2:
Practice Address - City:TOWNSEND
Practice Address - State:MA
Practice Address - Zip Code:01469-1096
Practice Address - Country:US
Practice Address - Phone:978-597-2327
Practice Address - Fax:978-597-8593
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9757643Medicaid
JO2174Medicare ID - Type Unspecified
MA9757643Medicaid