Provider Demographics
NPI:1922091735
Name:BROCK, RUSSELL LEE (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LEE
Last Name:BROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8700 STONY POINT PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-1962
Mailing Address - Country:US
Mailing Address - Phone:804-775-4500
Mailing Address - Fax:804-545-1632
Practice Address - Street 1:8700 STONY POINT PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-1962
Practice Address - Country:US
Practice Address - Phone:804-775-4500
Practice Address - Fax:804-545-1632
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101235511207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAF68697Medicare UPIN
VA003988R94Medicare ID - Type Unspecified