Basic Information
| Provider Information | |||||||||
| NPI: | 1902340342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | BROCK | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | SUITE 130 - PROVIDER ENROLLMENT | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172469128 | ||||||||
| FaxNumber: | 3179624343 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478042706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387523 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2016 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 10002173A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.