Healthcare Provider Details

I. General information

NPI: 1174583900
Provider Name (Legal Business Name): BROOKS F BOCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BUCK CREEK ROAD SUITE 200
AVON CO
81620
US

IV. Provider business mailing address

PO BOX 4330
AVON CO
81620-4330
US

V. Phone/Fax

Practice location:
  • Phone: 970-926-6340
  • Fax: 970-926-6348
Mailing address:
  • Phone: 970-926-6340
  • Fax: 970-926-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number35927
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4301029318
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier80885039
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 2
Identifier101709949
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 3
Identifier101987786
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 4
IdentifierBB029318
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerBC/BS OF MI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: