Provider Demographics
NPI:1770032708
Name:CHURCH, ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
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 1:2402 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1914
Mailing Address - Country:US
Mailing Address - Phone:269-281-0293
Mailing Address - Fax:
Practice Address - Street 1:2402 S STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1914
Practice Address - Country:US
Practice Address - Phone:269-281-0293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine