Provider Demographics
NPI:1467487868
Name:CHURCH, GALEN (DO)
Entity Type:Individual
Prefix:DR
First Name:GALEN
Middle Name:
Last Name:CHURCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 161959
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-1959
Mailing Address - Country:US
Mailing Address - Phone:916-346-4219
Mailing Address - Fax:
Practice Address - Street 1:1411 EXPO PKWY STE 140
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4239
Practice Address - Country:US
Practice Address - Phone:916-346-4219
Practice Address - Fax:916-426-5757
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO23047207P00000X, 207Q00000X
CA20A8620207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX86200Medicaid
CA020A86200Medicare PIN
CAH63268Medicare UPIN
CA020A86202Medicare PIN