Basic Information
Provider Information | |||||||||
NPI: | 1487865325 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANOCK | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | ROBERT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 99 | ||||||||
Address2: |   | ||||||||
City: | PARROTTSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378430099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4236251170 | ||||||||
FaxNumber: | 4236253618 | ||||||||
Practice Location | |||||||||
Address1: | 111 MOCKINGBIRD AVE | ||||||||
Address2: |   | ||||||||
City: | PARROTTSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 37843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4236251170 | ||||||||
FaxNumber: | 4236253618 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2007 | ||||||||
LastUpdateDate: | 11/22/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 42357 | TN | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | R4870 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3000070 | 05 | TN |   | MEDICAID | 30000701 | 05 | TN |   | MEDICAID | 4156905 | 01 | TN | BCBST | OTHER | 4156911 | 01 | TN | BCBST | OTHER | 30000704 | 05 | TN |   | MEDICAID | 4156909 | 01 | TN | BCBST | OTHER | 30000702 | 05 | TN |   | MEDICAID | 30000703 | 05 | TN |   | MEDICAID | 4156907 | 01 | TN | BCBST | OTHER | 4156913 | 01 | TN | BCBST | OTHER |