Provider Demographics
NPI:1174621767
Name:BROCKMAN, ROBERT J (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 HWY 17 BYPASS
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-4381
Mailing Address - Country:US
Mailing Address - Phone:843-652-8390
Mailing Address - Fax:843-652-8399
Practice Address - Street 1:75 BAYLOR DR STE 290
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-8965
Practice Address - Country:US
Practice Address - Phone:843-705-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500519208600000X
SC242632086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC24263OtherMEDICAL LICENSE
NC2213118AMedicare PIN
NC8918574Medicaid