Physician Compare National (NPI:1689761280)

HEALTHCARE PROVIDER: CHARLES E BROCK JR. M.D.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1689761280
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	9032014279
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20031205000114
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	BROCK
	Individual professional last name
Provider First Name	CHARLES
	Individual professional first name
Provider Middle Name	F
	Individual professional middle name
Provider Name Suffix Text	JR.
	The name suffix of the provider if the provider is an individual. The name suffix is a ''generation-related'' suffix, such as Jr., Sr., II, III, IV, or V.
Provider Gender	M
	The provider's gender if the provider is a person.
Provider Credential Text	MD
	The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.

Medical School Information
Medical School Name	UNIVERSITY OF MISSISSIPPI SCHOOL OF MEDICINE
	Individual professional's medical school
Graduation Year	1986
	Individual professional's medical school graduation year
Primary Specialty	FAMILY MEDICINE
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Organization Legal Name	BOLIVAR PHYSICIAN PRACTICES LLC
	Legal name of the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Group Practice PAC ID	6305995895
	Unique Group Practice ID assigned by PECOS to the Group Practice that the individual professional works with- will be blank if the address is not linked to a Group Practice
Number of Group Practice members	15
	Total number of individual professionals affiliated with the Group Practice based on Group Practice PAC ID
Line 1 Street Address	907 E SUNFLOWER RD
	Group Practice or individual's line 1 address
Marker of address line 2 suppression	Y
	Marker that address as reported may be incomplete
City	CLEVELAND
	Group Practice or individual's city
State	MS
	Group Practice or individual's state
Zip Code	387322830
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	250093
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	BOLIVAR MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 1
Hospital Affiliation CCN 2	251318
	Medicare CCN of hospital where individual professional provides service 2
Hospital Affiliation LBN 2	NORTH SUNFLOWER MEDICAL CENTER CAH
	Legal business name of hospital where individual professional provides service 2
Professional Accepts Medicare Assignment	Y