Basic Information
| Provider Information | |||||||||
| NPI: | 1275075152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCKMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5348 LAMME RD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454393215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375344651 | ||||||||
| FaxNumber: | 9375228799 | ||||||||
| Practice Location | |||||||||
| Address1: | 5348 LAMME RD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454393215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375344651 | ||||||||
| FaxNumber: | 9375228799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2016 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | APRN.CNP.024158 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0342029 | 05 | OH | MEDICAID | H709731 | 01 | OH | MEDICARE | OTHER |