Provider Demographics
NPI:1487865325
Name:MANOCK, STEPHEN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ROBERT
Last Name:MANOCK
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 99
Mailing Address - Street 2:
Mailing Address - City:PARROTTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37843-0099
Mailing Address - Country:US
Mailing Address - Phone:423-625-1170
Mailing Address - Fax:423-625-3618
Practice Address - Street 1:111 MOCKINGBIRD AVE
Practice Address - Street 2:
Practice Address - City:PARROTTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37843
Practice Address - Country:US
Practice Address - Phone:423-625-1170
Practice Address - Fax:423-625-3618
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42357207Q00000X
TXR4870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000070Medicaid
TN30000701Medicaid
TN4156905OtherBCBST
TN4156911OtherBCBST
TN30000704Medicaid
TN4156909OtherBCBST
TN30000702Medicaid
TN30000703Medicaid
TN4156907OtherBCBST
TN4156913OtherBCBST
TN30000701Medicare PIN
TN30000704Medicaid
TN30000704Medicare PIN
TN4156913OtherBCBST
TN30000703Medicare PIN
TN30000702Medicare PIN