Provider Demographics
NPI:1710069026
Name:CHURCH, NANCY R G (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:R G
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 1:10735 S CICERO AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5400
Mailing Address - Country:US
Mailing Address - Phone:708-581-5866
Mailing Address - Fax:708-581-5877
Practice Address - Street 1:10735 S CICERO AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5400
Practice Address - Country:US
Practice Address - Phone:708-581-5866
Practice Address - Fax:708-581-5877
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085259207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG20955Medicare UPIN
570390Medicare ID - Type Unspecified