Individual
SHOSHANA B CHURCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
1006 SOUTH DIVISION STREET, CARTERVILLE, IL 62918-1539
(618) 985-4841
(618) 985-8101
Mailing address
P O BOX 577, 109 CALIFORNIA, CARTERVILLE, IL 62918-0577
(618) 985-8221
(618) 985-4635
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085-002122
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
085002122
—
IL
01
—
141816
MEDICARE FQHC FOR SHAWNEE HEALTH SERVICES
IL
01
—
169746
HEALTH ALLIANCE
IL
05
—
370966854004
—
IL
01
—
CF3444
MEDICARE RR
IL
Enumeration date
08/02/2005
Last updated
09/13/2012
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