Healthcare Provider Details

I. General information

NPI: 1609281153
Provider Name (Legal Business Name): JOHN J. BROCKLAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR MCHANEY HALL 404, DCO75.00
COLUMBIA MO
65212
US

IV. Provider business mailing address

1 HOSPITAL DR MCHANEY HALL 404, DCO75.00
COLUMBIA MO
65212-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-2000
  • Fax:
Mailing address:
  • Phone: 573-884-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD60826310
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2014018353
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: