MEDICARE: TIMOTHY ZACHARY BROCK M.D.

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	208600000X	Surgery Physician	LL30096	SC
2	208600000X	Surgery Physician	69551	GA

General Provider Information

NPI Number	:	1679772297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY ZACHARY BROCK M.D.

Provider Business Mailing Address
First Line	:	148 BILL CARRUTH PKWY
Second Line	:	SUITE 180
City	:	HIRAM
State	:	GA
Zip	:	30141-3754
Country	:	US
Telephone Number	:	770-445-4915
Fax Number	:	770-445-6876

Provider Business Practice Location Address
First Line	:	148 BILL CARRUTH PKWY
Second Line	:	SUITE 180
City	:	HIRAM
State	:	GA
Zip	:	30141-3754
Country	:	US
Telephone Number	:	770-445-4915
Fax Number	:	770-445-6876

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

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	12/10/2019

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