Provider Demographics
NPI:1689387623
Name:WILLIAM BRADFORD BROCK
Entity Type:Organization
Organization Name:WILLIAM BRADFORD BROCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-610-6726
Mailing Address - Street 1:1589 SPARTA ST STE 105
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1392
Mailing Address - Country:US
Mailing Address - Phone:931-815-3636
Mailing Address - Fax:931-815-3808
Practice Address - Street 1:1589 SPARTA ST STE 105
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1392
Practice Address - Country:US
Practice Address - Phone:931-815-3636
Practice Address - Fax:931-815-3808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty