Provider Demographics
NPI:1881960961
Name:NANCY R G CHURCH MD LLC
Entity type:Organization
Organization Name:NANCY R G CHURCH MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:773-233-6500
Mailing Address - Street 1:10725 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3135
Mailing Address - Country:US
Mailing Address - Phone:773-233-6500
Mailing Address - Fax:773-233-2369
Practice Address - Street 1:10725 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3135
Practice Address - Country:US
Practice Address - Phone:773-233-6500
Practice Address - Fax:773-233-2369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085259207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG20955Medicare UPIN