Provider Demographics
NPI:1902185598
Name:CHURCH, SAGE RYAN (DO)
Entity Type:Individual
Prefix:
First Name:SAGE
Middle Name:RYAN
Last Name:CHURCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22201 MOROSS RD
Mailing Address - Street 2:PBII SUITE 70
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2169
Mailing Address - Country:US
Mailing Address - Phone:313-343-3700
Mailing Address - Fax:313-343-4756
Practice Address - Street 1:22201 MOROSS RD
Practice Address - Street 2:PBII SUITE 70
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2169
Practice Address - Country:US
Practice Address - Phone:313-343-3700
Practice Address - Fax:313-343-4756
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101019349208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics