1326033879 NPI number — DR. STEVEN K BROCKMAN MD PHD

Table of content: DR. STEVEN K BROCKMAN MD PHD (NPI 1326033879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326033879 NPI number — DR. STEVEN K BROCKMAN MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCKMAN
Provider First Name:
STEVEN
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
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:
1326033879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1112 YANCEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28150-3672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-481-7713
Provider Business Mailing Address Fax Number:
704-235-1971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1112 YANCEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28150-3672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-481-7713
Provider Business Practice Location Address Fax Number:
704-235-1971
Provider Enumeration Date:
09/12/2005

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: 208VP0000X , with the licence number:  33212 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 33212 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1982129136 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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