Basic Information
| Provider Information | |||||||||
| NPI: | 1548261449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHURCH | ||||||||
| FirstName: | SHOSHANA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHURCH | ||||||||
| OtherFirstName: | BARBARA | ||||||||
| OtherMiddleName: | W | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P O BOX 577 | ||||||||
| Address2: | 109 CALIFORNIA | ||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629180577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189858221 | ||||||||
| FaxNumber: | 6189854635 | ||||||||
| Practice Location | |||||||||
| Address1: | 1006 SOUTH DIVISION STREET | ||||||||
| Address2: | |||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629181539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189854841 | ||||||||
| FaxNumber: | 6189858101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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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 | 363A00000X | 085-002122 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085002122 | 05 | IL | MEDICAID | 169746 | 01 | IL | HEALTH ALLIANCE | OTHER | CF3444 | 01 | IL | MEDICARE RR | OTHER | 141816 | 01 | IL | MEDICARE FQHC FOR SHAWNEE HEALTH SERVICES | OTHER | 370966854004 | 05 | IL | MEDICAID |