Provider Demographics
NPI:1689854523
Name:ROBERT J BROCK MD PC
Entity Type:Organization
Organization Name:ROBERT J BROCK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-733-8333
Mailing Address - Street 1:PO BOX 941
Mailing Address - Street 2:480 S CACHE
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0941
Mailing Address - Country:US
Mailing Address - Phone:307-733-8333
Mailing Address - Fax:307-733-7929
Practice Address - Street 1:480 S CACHE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-0941
Practice Address - Country:US
Practice Address - Phone:307-733-8333
Practice Address - Fax:307-733-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7758A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty