Provider Demographics
NPI:1619910908
Name:BROCK, CHARLENE M (MD)
Entity Type:Individual
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First Name:CHARLENE
Middle Name:M
Last Name:BROCK
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Gender:F
Credentials:MD
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Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:2ND FLOOR TPI
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-926-9019
Mailing Address - Fax:215-226-8286
Practice Address - Street 1:8500 HENRY AVE
Practice Address - Street 2:TPI HENRY AVENUE PEDIATRICS
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2111
Practice Address - Country:US
Practice Address - Phone:215-483-8865
Practice Address - Fax:215-483-8027
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-08-14
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Provider Licenses
StateLicense IDTaxonomies
PAMD022704E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA436710OtherCOVENTRY HEALTH AMERICA
PA102057OtherHIGHMARK BLUE SHIELD
PA5406099OtherAETNA PPO
PA0016346OtherAETNA HMO
PA30030891OtherKEYSTONE MERCY HEALTH PLA
PA3Y7184OtherHEALTH NET
PA0055530000OtherINDEPENDENCE BLUE CROSS
PA102057Medicare PIN
PA0016346OtherAETNA HMO