1669589776 NPI number — GERALD K BROCKER JR. MD

Table of content: GERALD K BROCKER JR. MD (NPI 1669589776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669589776 NPI number — GERALD K BROCKER JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCKER
Provider First Name:
GERALD
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1669589776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2930
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46206-2930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-468-9496
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
975 E. THIRD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37403-2147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-602-8400
Provider Business Practice Location Address Fax Number:
423-602-8401
Provider Enumeration Date:
08/24/2006

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: 207L00000X , with the licence number:  MD22077 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207L00000X , with the licence number: 043334 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3038764 . This is a "BLUE CROSS BLUE SHIELD OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000500596A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q002744 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009204600 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 050047698 . This is a "RR MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 890692T , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: N348394 . This is a "WELLCARE (GA MEDICAID)" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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