Provider Demographics
NPI:1578545968
Name:SHROCK, MICHAEL B (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:SHROCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-9121
Mailing Address - Country:US
Mailing Address - Phone:601-656-8545
Mailing Address - Fax:601-656-3985
Practice Address - Street 1:1056 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-9121
Practice Address - Country:US
Practice Address - Phone:601-656-8545
Practice Address - Fax:601-656-3985
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080105518OtherRAILROAD MEDICARE
MS00113242Medicaid
C78786Medicare UPIN
080105518OtherRAILROAD MEDICARE