Basic Information
| Provider Information | |||||||||
| NPI: | 1164466827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHURCH | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376014877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234310509 | ||||||||
| FaxNumber: | 4237222060 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376014877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239292584 | ||||||||
| FaxNumber: | 4235425109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 02/20/2018 | ||||||||
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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 | 207Q00000X | 38090 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35082925 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 200701334 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 47644 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DR0646 | 01 | NC | RAILROAD MEDICARE | OTHER | 023U2 | 01 | NC | BLUE CROSSS BLUE SHIELD OF NC | OTHER |