=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376730838
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT J. BROCKER M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2007
-----------------------------------------------------
Last Update Date | 02/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1616 COVINGTON ST
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44510-1244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-747-9215
-----------------------------------------------------
Fax | 330-747-9248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1616 COVINGTON ST
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44510-1244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-747-9215
-----------------------------------------------------
Fax | 330-747-9248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. LINDA J EISENBRAUN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-747-9215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 35-053079
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------