Provider Demographics
NPI:1669589776
Name:BROCKER, GERALD K JR (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:K
Last Name:BROCKER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2930
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2930
Mailing Address - Country:US
Mailing Address - Phone:844-468-9496
Mailing Address - Fax:
Practice Address - Street 1:975 E. THIRD STREET
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-602-8400
Practice Address - Fax:423-602-8401
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD22077207L00000X
GA043334207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3038764OtherBLUE CROSS BLUE SHIELD OF TN
GA000500596AMedicaid
TNQ002744Medicaid
AL009204600Medicaid
TN050047698OtherRR MEDICARE
NC890692TMedicaid
GAN348394OtherWELLCARE (GA MEDICAID)
TNQ002744Medicaid
TN3038764OtherBLUE CROSS BLUE SHIELD OF TN