Basic Information
| Provider Information | |||||||||
| NPI: | 1982635553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | HOWARD | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 914 BROAD ST | ||||||||
| Address2: | STE 2A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232456101 | ||||||||
| FaxNumber: | 4232452396 | ||||||||
| Practice Location | |||||||||
| Address1: | 914 BROAD ST | ||||||||
| Address2: | STE 2A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232456101 | ||||||||
| FaxNumber: | 4232452396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD11147 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 033503 | 01 | VA | ANTHEM BCBS OF VIRGINIA | OTHER | 3173373 | 05 | TN | MEDICAID | 5961032 | 01 | AETNA | OTHER | 20009691 | 01 | TN | RAILROAD MEDICARE | OTHER | 7305605 | 01 | VA | VIRGINIA MEDICAID | OTHER | 0060917 | 01 | TN | BCBS TENNESSEE | OTHER |