Basic Information
| Provider Information | |||||||||
| NPI: | 1659543536 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROCK EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8050 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191018050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007321066 | ||||||||
| FaxNumber: | 6309414333 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 N SHELBY ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471672304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128835881 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2008 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8003550808 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000175329 | 01 | IN | BLUE SHIELD | OTHER |