DANE JACK CHURCH MD Medical Doctor License verification

Business Entity

CANCELLED

License Type

Medical Doctor

Description

TEMPORARY MEDICAL PERMIT

License Number

125071633

License Status

CANCELLED

Business

Title

First Name

DANE

Middle

JACK

Last Name

CHURCH

Business Name

DANE JACK CHURCH MD

Original Issue Date

08/01/2018

Effective Date

08/01/2018

Expiration Date

07/31/2019

City

SPRINGFIELD

State

Zip

62701

County

SANGAMON

Specialty/Qualifier

Adult Reconstructive Orthopedics

Ever Disciplined

LastModifiedDate

03/30/2018