Provider Demographics
NPI:1609842657
Name:BROCK, MEGAN (PA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:COHLHEPP
Other - Suffix:
Other - Last Name Type:Former Name
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 1:123 2ND ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-6705
Practice Address - Country:US
Practice Address - Phone:812-342-3339
Practice Address - Fax:812-342-3352
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000803A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00243883OtherRRMC
IN066790OtherSIHO
IN000000386806OtherBCBS
INP00243883OtherRRMC