Provider Demographics
NPI:1568697753
Name:BROCK, KYLE FRANKLIN (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:FRANKLIN
Last Name:BROCK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3700
Mailing Address - Fax:414-805-3777
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3700
Practice Address - Fax:414-805-3777
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2014-07-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO20100190142085R0202X
WI623982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568697753Medicaid
WIK400146469Medicare PIN