Healthcare Provider Details

I. General information

NPI: 1417948043
Provider Name (Legal Business Name): PEDIATRICS IN BREVARD, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 W COCOA BEACH CSWY STE 401
COCOA BEACH FL
32931-3562
US

IV. Provider business mailing address

699 W COCOA BEACH CSWY
COCOA BEACH FL
32931-3577
US

V. Phone/Fax

Practice location:
  • Phone: 321-784-5437
  • Fax: 321-799-1231
Mailing address:
  • Phone: 321-784-5437
  • Fax: 321-799-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier253255705
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name: MELISSA LOISELLE
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 321-877-4438