Provider Demographics
NPI:1346291713
Name:MOCK, ROBERT BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRADLEY
Last Name:MOCK
Suffix:
Gender:M
Credentials:MD
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 1657
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29622-1657
Mailing Address - Country:US
Mailing Address - Phone:864-225-4601
Mailing Address - Fax:864-225-6998
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-225-4601
Practice Address - Fax:864-225-6998
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14456207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC144560Medicaid
SC571041534OtherEMPLOYER EIN
SC571041534OtherEMPLOYER EIN
SC5102Medicare PIN
SC144560Medicaid