Provider Demographics
NPI:1083813182
Name:CHURCH, AN LY (MD)
Entity type:Individual
Prefix:
First Name:AN
Middle Name:LY
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 FULTON ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-4800
Mailing Address - Country:US
Mailing Address - Phone:1612-672-7422
Mailing Address - Fax:612-273-4370
Practice Address - Street 1:909 FULTON ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4800
Practice Address - Country:US
Practice Address - Phone:161-267-2742
Practice Address - Fax:612-672-7422
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN607032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100248470Medicaid
KY7100248470Medicaid
ININ1304018Medicare PIN