Provider Demographics
NPI:1225057896
Name:MOCK, BRYAN RONALD (DC)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:RONALD
Last Name:MOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 GREENTREE RD
Mailing Address - Street 2:UNIT A-114
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15220-1400
Mailing Address - Country:US
Mailing Address - Phone:412-668-2089
Mailing Address - Fax:412-207-9077
Practice Address - Street 1:2101 GREENTREE RD
Practice Address - Street 2:UNIT A-114
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15220-1400
Practice Address - Country:US
Practice Address - Phone:412-668-2089
Practice Address - Fax:412-207-9077
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC 007729L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMO 129568OtherBLUE CROSS INDIVIDUAL #
PANA 181935OtherBLUE CROSS GROUP NUMBER
PWU83079Medicare UPIN
PA01833171Medicaid
PA044227Medicare ID - Type Unspecified
PA7731830OtherCIGNA PROVIDER #