Basic Information
| Provider Information | |||||||||
| NPI: | 1497723027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROCK | ||||||||
| FirstName: | ALICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEATON | ||||||||
| OtherFirstName: | ALICE | ||||||||
| OtherMiddleName: | ROCK | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6431 FANNIN ST | ||||||||
| Address2: | SUITE MSB 5.111 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770305389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135006325 | ||||||||
| FaxNumber: | 7135000706 | ||||||||
| Practice Location | |||||||||
| Address1: | 6431 FANNIN ST. | ||||||||
| Address2: | SUITE MSB5.111 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770305389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135006325 | ||||||||
| FaxNumber: | 7135000706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 29505-20 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 063644D6X | 05 | PA | MEDICAID |