Healthcare Provider Details

I. General information

NPI: 1023179090
Provider Name (Legal Business Name): THEODORE K SCHOCK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 W GIBSON ST
HARTWELL GA
30643-1845
US

IV. Provider business mailing address

PO BOX 459
COLBERT GA
30628-0459
US

V. Phone/Fax

Practice location:
  • Phone: 706-376-6100
  • Fax: 706-376-3394
Mailing address:
  • Phone: 706-788-3234
  • Fax: 706-788-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number030882
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: