Healthcare Provider Details

I. General information

NPI: 1275811077
Provider Name (Legal Business Name): MATTHEW RYAN BROCK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 FRANK MARTIN RD
SHELBYVILLE TN
37160-7192
US

IV. Provider business mailing address

3841 GREEN HILLS VILLAGE DR STE 200
NASHVILLE TN
37215-2691
US

V. Phone/Fax

Practice location:
  • Phone: 931-684-5554
  • Fax:
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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3790
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: