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NPI Code Detail

MEDICARE: JONATHAN RUSSELL BROCK M.D.

MEDICARE: JONATHAN RUSSELL 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
1207R00000XInternal Medicine Physician2022-00009NC
2390200000XStudent in an Organized Health Care Education/Training Program
3207RC0001XClinical Cardiac Electrophysiology Physician102044GA

General Provider Information

NPI Number : 1871927269
Entity Type Code : Individual
Provider Name (Legal Business Name) : JONATHAN RUSSELL BROCK M.D.
Provider Business Mailing Address
First Line : 1062 FORSYTH ST STE 1B
Second Line :
City : MACON
State : GA
Zip : 31201-8638
Country : US
Telephone Number : 478-741-1208
Fax Number : 478-741-1557
Provider Business Practice Location Address
First Line : 1062 FORSYTH ST STE 1B
Second Line :
City : MACON
State : GA
Zip : 31201-8638
Country : US
Telephone Number : 478-741-1208
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/21/2013
Last Update Date : 08/19/2025

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