MEDICARE: CHARLENE M BROCK MD

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	208000000X	Pediatrics Physician	MD022704E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	436710	OTHER	PA	COVENTRY HEALTH AMERICA
2	102057	OTHER	PA	HIGHMARK BLUE SHIELD
3	5406099	OTHER	PA	AETNA PPO
4	0016346	OTHER	PA	AETNA HMO
5	30030891	OTHER	PA	KEYSTONE MERCY HEALTH PLA
6	3Y7184	OTHER	PA	HEALTH NET
7	0055530000	OTHER	PA	INDEPENDENCE BLUE CROSS

General Provider Information

NPI Number	:	1619910908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLENE M BROCK MD

Provider Business Mailing Address
First Line	:	2450 W HUNTING PARK AVE
Second Line	:	2ND FLOOR TPI
City	:	PHILADELPHIA
State	:	PA
Zip	:	19129-1302
Country	:	US
Telephone Number	:	215-926-9019
Fax Number	:	215-226-8286

Provider Business Practice Location Address
First Line	:	8500 HENRY AVE
Second Line	:	TPI HENRY AVENUE PEDIATRICS
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-2111
Country	:	US
Telephone Number	:	215-483-8865
Fax Number	:	215-483-8027

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	08/14/2007

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Directions to “ CHARLENE M BROCK MD” Practice Location

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