Provider Demographics
NPI:1336279132
Name:YOUNGSTOWN NEUROLOGIC ASSOCIATES
Entity Type:Organization
Organization Name:YOUNGSTOWN NEUROLOGIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-09049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000104951OtherUNISON #
OH1526878OtherPA MEDICAID #
OH0034184OtherCHAMPUS #
OH0120489Medicaid
OH1526878OtherPA MEDICAID #
OH=========4AOOOtherANTHEM #
OH1526878OtherPA MEDICAID #