Provider Demographics
NPI:1780659698
Name:ROGER BROCK
Entity type:Organization
Organization Name:ROGER BROCK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:RPSGT
Authorized Official - Phone:717-312-1441
Mailing Address - Street 1:1512 E CARACAS AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-1184
Mailing Address - Country:US
Mailing Address - Phone:717-312-1441
Mailing Address - Fax:717-312-0441
Practice Address - Street 1:1512 E CARACAS AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-1184
Practice Address - Country:US
Practice Address - Phone:717-312-1441
Practice Address - Fax:717-312-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA209611OtherHEALTH AMERICA/ HEALTH AS
PA30000583OtherKEYSTONE
PA3138777OtherAETNA - HMO
PA7567457OtherAETNA NON-HMO
PW50017664OtherCAPITAL BLUE CROSS
PASL1598571OtherHIGHMARK
PASL1598571OtherHIGHMARK