Healthcare Provider Details

I. General information

NPI: 1124691159
Provider Name (Legal Business Name): BREVARD PHYSICIAN ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8075 SPYGLASS HILL RD
MELBOURNE FL
32940-8281
US

IV. Provider business mailing address

PO BOX 8002
SALEM NH
03079-8002
US

V. Phone/Fax

Practice location:
  • Phone: 321-837-3820
  • Fax:
Mailing address:
  • Phone: 800-927-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTY R BROWN
Title or Position: MEMBER
Credential: M.D.
Phone: 321-255-9671