Provider Demographics
NPI:1154374668
Name:BROCK, GINA (DO)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 E 66TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5701
Mailing Address - Country:US
Mailing Address - Phone:912-350-8837
Mailing Address - Fax:912-350-5118
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102907207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00164456OtherRAILROAD MEDICARE - FLAGL
FLU3639Medicare ID - Type Unspecified
FLP00164456OtherRAILROAD MEDICARE - FLAGL