Basic Information
| Provider Information | |||||||||
| NPI: | 1669436671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STROCK | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 SUITE 360 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1199 HADLEY RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461581788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175288494 | ||||||||
| FaxNumber: | 3175287118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 01060580 | IN | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 200513380 | 05 | IN | MEDICAID | 000000626047 | 01 | IN | ANTHEM BCBS | OTHER |