Basic Information
Provider Information | |||||||||
NPI: | 1629051198 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROCK | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 MERCHANT STREET | ||||||||
Address2: | SUITE 220 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452463740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135331199 | ||||||||
FaxNumber: | 5136459787 | ||||||||
Practice Location | |||||||||
Address1: | 10530 HARRISON AVE | ||||||||
Address2: |   | ||||||||
City: | HARRISON | ||||||||
State: | OH | ||||||||
PostalCode: | 450302141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5133670775 | ||||||||
FaxNumber: | 5133674714 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2005 | ||||||||
LastUpdateDate: | 01/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 36002705 | OH | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 100328030B | 05 | IN |   | MEDICAID | 480025150 | 01 | OH | MEDICARE RR | OTHER | 0882568 | 05 | OH |   | MEDICAID |