Healthcare Provider Details

I. General information

NPI: 1891767695
Provider Name (Legal Business Name): ROBERT COLEMAN BROCK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26400 PLYMOUTH RD
REDFORD MI
48239-2213
US

IV. Provider business mailing address

26400 PLYMOUTH RD
REDFORD MI
48239-2213
US

V. Phone/Fax

Practice location:
  • Phone: 313-937-9318
  • Fax: 313-937-1183
Mailing address:
  • Phone: 313-937-9318
  • Fax: 313-937-1183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101010279
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: