Healthcare Provider Details

I. General information

NPI: 1871927269
Provider Name (Legal Business Name): JONATHAN RUSSELL BROCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 FORSYTH ST STE 1B
MACON GA
31201-8638
US

IV. Provider business mailing address

1062 FORSYTH ST STE 1B
MACON GA
31201-8638
US

V. Phone/Fax

Practice location:
  • Phone: 478-741-1208
  • Fax:
Mailing address:
  • Phone: 478-741-1208
  • Fax: 478-741-1557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2022-00009
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number102044
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: