Provider Demographics
NPI:1861583528
Name:GENERALOVICH, BROCK (DO)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:GENERALOVICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:7629 MARKET ST STE 200
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6082
Mailing Address - Country:US
Mailing Address - Phone:330-965-4540
Mailing Address - Fax:330-965-4559
Practice Address - Street 1:7641 MARKET ST STE 2
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-5980
Practice Address - Country:US
Practice Address - Phone:330-726-3724
Practice Address - Fax:330-726-3725
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2015-02-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH34-008611208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI44817Medicare UPIN