Provider Demographics
NPI:1871585034
Name:CHURCH, FREDERICK WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:CHURCH
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:7180 SPRING BROOK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6700
Mailing Address - Country:US
Mailing Address - Phone:815-971-2299
Mailing Address - Fax:815-971-9749
Practice Address - Street 1:7180 SPRING BROOK RD
Practice Address - Street 2:SUITE B
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6700
Practice Address - Country:US
Practice Address - Phone:815-971-2299
Practice Address - Fax:815-971-9749
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036044472208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC36995Medicare UPIN
IL207571Medicare PIN