Healthcare Provider Details

I. General information

NPI: 1649383720
Provider Name (Legal Business Name): SPACE COAST INTERNAL MEDICINE & GERIATRIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 PALM ST
COCOA FL
32927-5145
US

IV. Provider business mailing address

PO BOX 549
SHARPES FL
32959-0549
US

V. Phone/Fax

Practice location:
  • Phone: 321-639-4243
  • Fax: 321-639-4266
Mailing address:
  • Phone: 321-639-4243
  • Fax: 321-639-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME72416
License Number StateFL

VIII. Authorized Official

Name: DAVID ROMANELLO
Title or Position: COO
Credential:
Phone: 352-459-3661