1043286594 NPI number — JOSEPH L BROCK MD

Table of content: JOSEPH L BROCK MD (NPI 1043286594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043286594 NPI number — JOSEPH L BROCK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK
Provider First Name:
JOSEPH
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1043286594
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 547
Provider Second Line Business Mailing Address:
ATT: CVMC FINANCE DEPT
Provider Business Mailing Address City Name:
BARRE
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05641-0547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-225-5810
Provider Business Mailing Address Fax Number:
802-371-4821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
246 GRANGER RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BARRE
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05641-5344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-225-5810
Provider Business Practice Location Address Fax Number:
802-371-4821
Provider Enumeration Date:
02/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301047460 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 042.0011623 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5621038 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 101317 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 34918 . This is a "HEALTH PLAN OF MI" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 6589077 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0806100351 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1015396 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0806100351 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 300207909004 . This is a "TRICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4556208 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4556208 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: A74772 . This is a "PRIORITY HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P00091158 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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