Basic Information
| Provider Information | |||||||||
| NPI: | 1952577348 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROCK | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 EUCLID AVE | ||||||||
| Address2: | M2 ANNEX | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441957112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164440933 | ||||||||
| FaxNumber: | 2164448530 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 EUCLID AVE | ||||||||
| Address2: | M2 ANNEX | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164440933 | ||||||||
| FaxNumber: | 2164448530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 03/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34.009916 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3109675 | 05 | OH | MEDICAID |