Healthcare Provider Details

I. General information

NPI: 1164927307
Provider Name (Legal Business Name): BENJAMIN ROBERT BROCKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 01/08/2022
Certification Date: 01/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7341 EISENHOWER DR
BOARDMAN OH
44512-5900
US

IV. Provider business mailing address

8423 MARKET ST STE 101
BOARDMAN OH
44512-6778
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-1138
  • Fax: 330-726-6128
Mailing address:
  • Phone: 330-729-8700
  • Fax: 330-729-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.015108
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: