Provider Demographics
NPI:1154794741
Name:PAUL A CHURCH MD PC
Entity type:Organization
Organization Name:PAUL A CHURCH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-983-7019
Mailing Address - Street 1:1153 CENTRE ST
Mailing Address - Street 2:SUITE 5930
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3446
Mailing Address - Country:US
Mailing Address - Phone:617-983-7019
Mailing Address - Fax:617-983-7533
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:SUITE 5930
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7019
Practice Address - Fax:617-983-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57851208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty