Provider Demographics
NPI:1003882291
Name:HALLOCK, EDWARD BRIAN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:BRIAN
Last Name:HALLOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-602-8400
Mailing Address - Fax:423-602-8401
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-602-8400
Practice Address - Fax:423-602-8401
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN10767367500000X
TNRN99856367500000X
GARN163737367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3631302Medicaid
TN4033046OtherBCBS
TN103I438362Medicare PIN
GA43ZCBSZ120Medicare ID - Type Unspecified
TN4033046OtherBCBS