Basic Information
| Provider Information | |||||||||
| NPI: | 1699887398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCDANIELS | ||||||||
| OtherFirstName: | REGINA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 858 EASTERN BYP | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404752512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596260072 | ||||||||
| FaxNumber: | 8596269684 | ||||||||
| Practice Location | |||||||||
| Address1: | 858 EASTERN BYP | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404752512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596260072 | ||||||||
| FaxNumber: | 8596269684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34004 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34204 | 01 | KY | MED LIC (KY BOARD OF MED) | OTHER | 64050768 | 05 | KY | MEDICAID | BM6058247 | 01 | DEPT OF JUSTICE - DEA | OTHER |