Provider Demographics
NPI:1861451742
Name:HORSLEY, BROCK WELLS (DO)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:WELLS
Last Name:HORSLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:602 BEECH ST
Mailing Address - Street 2:STE 3210
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1466
Mailing Address - Country:US
Mailing Address - Phone:989-802-8464
Mailing Address - Fax:989-802-8815
Practice Address - Street 1:602 BEECH ST
Practice Address - Street 2:STE 3210
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1466
Practice Address - Country:US
Practice Address - Phone:989-802-8464
Practice Address - Fax:989-802-8815
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101014871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0101842OtherPHYSICIANS HEALTH PLAN
MI610677100OtherUS DEPT OF LABOR
MI0853701105OtherBCBS OF MICHIGAN NUMBER
MI1012731OtherMCLAREN HEALTH PLAN
MI114637450Medicaid
MII17657Medicare UPIN
MIN99520001Medicare ID - Type UnspecifiedMEDICARE NUMBER