Healthcare Provider Details

I. General information

NPI: 1912584160
Provider Name (Legal Business Name): BROCK ALLEN LANDRUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

525 E MARKET ST
AKRON OH
44304-1619
US

V. Phone/Fax

Practice location:
  • Phone: 859-757-2927
  • Fax: 859-341-0203
Mailing address:
  • Phone:
  • Fax:

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 State
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number61701
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.148776
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: