1164677993 NPI number — TYLER CHURCH, MD, PC

Table of content: MS. GINA MARIE BAUDILLE LMFT (NPI 1932693215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164677993 NPI number — TYLER CHURCH, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TYLER CHURCH, MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164677993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1847
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85299-1847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-507-2961
Provider Business Mailing Address Fax Number:
480-507-2971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1955 W FRYE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85224-6282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-507-2961
Provider Business Practice Location Address Fax Number:
480-507-2971
Provider Enumeration Date:
11/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CHURCH
Authorized Official First Name:
TYLER
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
480-507-2961

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  37949 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 350318 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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