Provider Demographics
NPI:1518987122
Name:CHURCHILL, JANE M (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:M
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:17833 COUNTY RD 40
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470
Mailing Address - Country:US
Mailing Address - Phone:218-732-9453
Mailing Address - Fax:
Practice Address - Street 1:600 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1431
Practice Address - Country:US
Practice Address - Phone:218-732-3311
Practice Address - Fax:218-732-1368
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN667368600Medicaid
MND80278Medicare UPIN