Provider Demographics
NPI:1376730838
Name:ROBERT J. BROCKER M.D., INC.
Entity Type:Organization
Organization Name:ROBERT J. BROCKER M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:EISENBRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:
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:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-053079174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000150690OtherUNISON
OH285520211008OtherMEDICAL MUTUAL-YNGS OFF
OH0640453Medicaid
OH285520211-00OtherBWC
OH9340971OtherMEDICARE-YNGS
OH000000323539OtherANTHEM
OH1538350OtherGATEWAY
OH4127012OtherAETNA
OH285520211009OtherMEDICAL MUTUAL-WARREN OFF
OH9340972OtherMEDICARE-WARREN
OH000000150690OtherUNISON
OH9340972OtherMEDICARE-WARREN