Healthcare Provider Details

I. General information

NPI: 1164071734
Provider Name (Legal Business Name): JAMES M BROCK CPSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 06/11/2026
Certification Date: 02/13/2023
Deactivation Date: 02/13/2023
Reactivation Date: 06/11/2026

III. Provider practice location address

2803 OLD NORTH HILLS ST
MERIDIAN MS
39305-1630
US

IV. Provider business mailing address

2803 OLD NORTH HILLS ST
MERIDIAN MS
39305-1630
US

V. Phone/Fax

Practice location:
  • Phone: 601-453-2919
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: