Provider Demographics
NPI:1578528436
Name:TIFFAULT, ROCK GERARD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROCK
Middle Name:GERARD
Last Name:TIFFAULT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1701 S CREASY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4972
Practice Address - Country:US
Practice Address - Phone:765-423-6165
Practice Address - Fax:765-502-4683
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1219207Q00000X, 207P00000X
IN01056196A208M00000X, 207Q00000X
WI39496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00471673OtherRR MEDICARE
TX1578528436OtherSCOTT & WHITE HEALTH PLAN
TX8AN220OtherBCBS TX
TX142079626Medicaid
IN220226600Medicaid
TX142079626Medicaid
TX8J9469Medicare PIN