Provider Demographics
NPI:1366419269
Name:CHURCH, ERIC JACK (M D)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JACK
Last Name:CHURCH
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3240 E UNION HILLS DR STE 131
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-2629
Mailing Address - Country:US
Mailing Address - Phone:480-265-0890
Mailing Address - Fax:602-297-6828
Practice Address - Street 1:3240 E UNION HILLS DR STE 131
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-2629
Practice Address - Country:US
Practice Address - Phone:480-265-0890
Practice Address - Fax:602-297-6828
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28649207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH05582Medicare UPIN