Provider Demographics
NPI:1871754127
Name:HOWARD R BROCK M.D.
Entity type:Organization
Organization Name:HOWARD R BROCK M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-570-7005
Mailing Address - Street 1:1436 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-1234
Mailing Address - Country:US
Mailing Address - Phone:423-570-7005
Mailing Address - Fax:
Practice Address - Street 1:1436 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-1234
Practice Address - Country:US
Practice Address - Phone:423-570-7005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000036269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN702025457OtherCARITEN
TNP00190427OtherRAILROAD MEDICARE
TN3357233OtherCIGNA
TN4095858OtherBLUE CROSS
TNTN0101OtherUNITED HEALTHCARE OF THE RIVER VALLEY
TNH78647Medicare UPIN
TN4095858OtherBLUE CROSS
TNTN0101OtherUNITED HEALTHCARE OF THE RIVER VALLEY