1770782674 NPI number — MICHAEL E. BROCK, D.O., P.S.C.

Table of content: (NPI 1770782674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770782674 NPI number — MICHAEL E. BROCK, D.O., P.S.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL E. BROCK, D.O., P.S.C.
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:
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:
1770782674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2920 WINCHESTER AVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41101-1962
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-326-0640
Provider Business Mailing Address Fax Number:
606-326-0650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2920 WINCHESTER AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41101-1962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-326-0640
Provider Business Practice Location Address Fax Number:
606-326-0650
Provider Enumeration Date:
07/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROCK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
606-326-0640

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 64081540 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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