Provider Demographics
NPI:1912394073
Name:HAUT, BROCK H (DPT)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:H
Last Name:HAUT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:1815 E IRELAND RD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-5790
Practice Address - Fax:574-647-5792
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008296A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201286940Medicaid
IN000001048225OtherANTHEM BEACON PHYSICAL THERAPY
IN201286940Medicaid
IN169380027Medicare PIN
IN000000930283OtherBCBS BMG IRELAND RD