Provider Demographics
NPI:1972643997
Name:ROBERT J BROCK MD PA
Entity Type:Organization
Organization Name:ROBERT J BROCK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-525-3220
Mailing Address - Street 1:PO BOX 3070
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3070
Mailing Address - Country:US
Mailing Address - Phone:208-525-3220
Mailing Address - Fax:208-525-3227
Practice Address - Street 1:2420 EAST 25TH CIRCLE
Practice Address - Street 2:SUITE B
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7549
Practice Address - Country:US
Practice Address - Phone:208-525-3220
Practice Address - Fax:208-525-3227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM79082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8055716000Medicaid
ID1376458Medicare ID - Type Unspecified