Provider Demographics
NPI:1407807464
Name:CHURCHILL, STEPHEN PAUL (PT/APT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:PAUL
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:PT/APT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0514
Mailing Address - Country:US
Mailing Address - Phone:701-258-7730
Mailing Address - Fax:701-258-7803
Practice Address - Street 1:2945 N 11TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0514
Practice Address - Country:US
Practice Address - Phone:701-258-7730
Practice Address - Fax:701-258-7803
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND26174OtherBCBS OF ND
ND51672Medicaid
ND51672Medicaid