Healthcare Provider Details

I. General information

NPI: 1336719061
Provider Name (Legal Business Name): MELBOURNE GYNECOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N WICKHAM RD STE 201
MELBOURNE FL
32935-8668
US

IV. Provider business mailing address

PO BOX 9100
BELFAST ME
04915-9100
US

V. Phone/Fax

Practice location:
  • Phone: 321-242-0035
  • Fax: 321-242-0075
Mailing address:
  • Phone: 561-300-2410
  • Fax: 561-235-7292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: ERICA HERNANDEZ
Title or Position: MANAGER
Credential:
Phone: 561-300-2410