Provider Demographics
NPI:1053398149
Name:CHURCH, SAMUEL LEROY (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:LEROY
Last Name:CHURCH
Suffix:
Gender:M
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:PO BOX 1217
Mailing Address - Street 2:
Mailing Address - City:HIAWASSEE
Mailing Address - State:GA
Mailing Address - Zip Code:30546-1217
Mailing Address - Country:US
Mailing Address - Phone:706-896-0505
Mailing Address - Fax:866-796-2502
Practice Address - Street 1:85 SEASONS LANE
Practice Address - Street 2:
Practice Address - City:HIAWASSEE
Practice Address - State:GA
Practice Address - Zip Code:30546-3217
Practice Address - Country:US
Practice Address - Phone:706-896-0505
Practice Address - Fax:866-796-2502
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA002342OtherBLUE CROSS BLUE SHIELD
GA000901271DMedicaid
GA930122977OtherMEDICARE RAILROAD
NC89066J3Medicaid
GAH37087Medicare UPIN
GAGRP4631Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
GA002342OtherBLUE CROSS BLUE SHIELD