Provider Demographics
NPI:1134316664
Name:BRIAN P. BROCKER M.D., INC
Entity Type:Organization
Organization Name:BRIAN P. BROCKER M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-747-9215
Mailing Address - Street 1:1616 COVINGTON ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44510-1244
Mailing Address - Country:US
Mailing Address - Phone:330-747-9215
Mailing Address - Fax:330-747-9248
Practice Address - Street 1:1616 COVINGTON ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44510-1244
Practice Address - Country:US
Practice Address - Phone:330-747-9215
Practice Address - Fax:330-747-9248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-066899174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7405468OtherCIGNA
OH9282452OtherMEDICARE-YNGS
OH4597438OtherAETNA
OH0600127OtherUNITED HEALTHCARE
OH285520215005OtherMEDICAL MUTUAL-WARREN LOC
OH285520215001OtherMEDICAL MUTUAL-YNGS LOC
OH000000138342OtherANTHEM
OH0215672Medicaid
OH1507678OtherGATEWAY
OH28552021500OtherBWC PROVIDER #
OH000000106032OtherUNISON
OH9282451OtherMEDICARE-WARREN
OH9282452OtherMEDICARE-YNGS
OH0600127OtherUNITED HEALTHCARE