1780659698 NPI number — ROGER BROCK

Table of content: (NPI 1780659698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780659698 NPI number — ROGER BROCK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROGER BROCK
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:
6
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:
1780659698
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1512 E CARACAS AVE
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
HERSHEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17033-1184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-312-1441
Provider Business Mailing Address Fax Number:
717-312-0441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1512 E CARACAS AVE
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
HERSHEY
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17033-1184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-312-1441
Provider Business Practice Location Address Fax Number:
717-312-0441
Provider Enumeration Date:
02/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROCK
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
717-312-1441

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 209611 . This is a "HEALTH AMERICA/ HEALTH AS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30000583 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3138777 . This is a "AETNA - HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7567457 . This is a "AETNA NON-HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50017664 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PW ) . This identifiers is of the category "OTHER".
  • Identifier: SL1598571 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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