1871754127 NPI number — HOWARD R BROCK M.D.

Table of content: (NPI 1871754127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871754127 NPI number — HOWARD R BROCK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOWARD R BROCK M.D.
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:
DAYTON FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
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:
1871754127
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1436 RAILROAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37321-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-570-7005
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1436 RAILROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37321-1234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-570-7005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BROCK
Authorized Official First Name:
HOWARD
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-570-7005

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD0000036269 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 702025457 . This is a "CARITEN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P00190427 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3357233 . This is a "CIGNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4095858 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN0101 . This is a "UNITED HEALTHCARE OF THE RIVER VALLEY" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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