Provider Demographics
NPI:1629051198
Name:BROCK, MICHAEL P (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:BROCK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32743 23 MILE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-2176
Mailing Address - Country:US
Mailing Address - Phone:708-424-3201
Mailing Address - Fax:708-424-5001
Practice Address - Street 1:10530 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:OH
Practice Address - Zip Code:45030-2141
Practice Address - Country:US
Practice Address - Phone:513-367-0775
Practice Address - Fax:513-367-4714
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2022-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002705213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100328030BMedicaid
OH480025150OtherMEDICARE RR
OH0882568Medicaid
IN100328030BMedicaid
0698420002Medicare NSC
0698420015Medicare NSC
OHBR0713645Medicare PIN
OHU30415Medicare UPIN