Provider Demographics
NPI:1770782674
Name:MICHAEL E. BROCK, D.O., P.S.C.
Entity type:Organization
Organization Name:MICHAEL E. BROCK, D.O., P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:606-326-0640
Mailing Address - Street 1:2920 WINCHESTER AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-1962
Mailing Address - Country:US
Mailing Address - Phone:606-326-0640
Mailing Address - Fax:606-326-0650
Practice Address - Street 1:2920 WINCHESTER AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-1962
Practice Address - Country:US
Practice Address - Phone:606-326-0640
Practice Address - Fax:606-326-0650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64081540Medicaid
KY9203Medicare PIN
KYI06160Medicare UPIN