Basic Information
| Provider Information | |||||||||
| NPI: | 1083813182 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHURCH | ||||||||
| FirstName: | AN | ||||||||
| MiddleName: | LY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 FULTON ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554554800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 16126727422 | ||||||||
| FaxNumber: | 6122734370 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 FULTON ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554554800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1612672742 | ||||||||
| FaxNumber: | 6126727422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 08/29/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 60703 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7100248470 | 05 | KY | MEDICAID |