Healthcare Provider Details

I. General information

NPI: 1003807637
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: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8057 SPYGLASS HILL RD STE 102
MELBOURNE FL
32940-8565
US

IV. Provider business mailing address

134 S WOODS DR
ROCKLEDGE FL
32955-3262
US

V. Phone/Fax

Practice location:
  • Phone: 321-435-9800
  • Fax: 321-435-9803
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MELISSA LOISELLE
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 321-435-9800