Provider Demographics
NPI:1548261449
Name:CHURCH, SHOSHANA B (PA)
Entity type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:B
Last Name:CHURCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:W
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:P O BOX 577
Mailing Address - Street 2:109 CALIFORNIA
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0577
Mailing Address - Country:US
Mailing Address - Phone:618-985-8221
Mailing Address - Fax:618-985-4635
Practice Address - Street 1:1006 SOUTH DIVISION STREET
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1539
Practice Address - Country:US
Practice Address - Phone:618-985-4841
Practice Address - Fax:618-985-8101
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002122363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085002122Medicaid
IL169746OtherHEALTH ALLIANCE
ILCF3444OtherMEDICARE RR
IL141816OtherMEDICARE FQHC FOR SHAWNEE HEALTH SERVICES
IL370966854004Medicaid
IL640701Medicare Oscar/Certification
IL370966854004Medicaid
K09990Medicare ID - Type Unspecified