Basic Information
| Provider Information | |||||||||
| NPI: | 1831191212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHURCH | ||||||||
| FirstName: | AMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 WEST GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | RED BANK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120051 | ||||||||
| FaxNumber: | 7322120713 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ROBERT WOOD JOHNSON PL | ||||||||
| Address2: | MEB 104 | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322358717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 206943 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01780592 | 05 | NY | MEDICAID |