Healthcare Provider Details

I. General information

NPI: 1285672733
Provider Name (Legal Business Name): BROCK MCCONNEHEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 N COLE RD
BOISE ID
83704-8638
US

IV. Provider business mailing address

888 N COLE RD
BOISE ID
83704-8638
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-6794
  • Fax:
Mailing address:
  • Phone: 208-452-6794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO207
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: