MEDICARE: MATTHEW RYAN BROCK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207Q00000X	Family Medicine Physician	3790	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	390200000X	OTHER	FL	STUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING PROGRAM

General Provider Information

NPI Number	:	1275811077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW RYAN BROCK D.O.

Provider Business Mailing Address
First Line	:	3841 GREEN HILLS VILLAGE DR STE 200
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37215-2691
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 FRANK MARTIN RD
Second Line	:
City	:	SHELBYVILLE
State	:	TN
Zip	:	37160-7192
Country	:	US
Telephone Number	:	931-684-5554
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2011
Last Update Date	:	03/21/2022

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