Provider Demographics
NPI:1659543536
Name:BROCK EMERGENCY PHYSICIANS
Entity Type:Organization
Organization Name:BROCK EMERGENCY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-355-0808
Mailing Address - Street 1:PO BOX 8050
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-8050
Mailing Address - Country:US
Mailing Address - Phone:800-732-1066
Mailing Address - Fax:630-941-4333
Practice Address - Street 1:911 N SHELBY ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IN
Practice Address - Zip Code:47167-2304
Practice Address - Country:US
Practice Address - Phone:812-883-5881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000175329OtherBLUE SHIELD
IN000000175329OtherBLUE SHIELD