Healthcare Provider Details

I. General information

NPI: 1396419032
Provider Name (Legal Business Name): NORTH BREVARD MEDICAL SUPPORT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 PORT ST JOHN PKWY STE 2300
PORT ST JOHN FL
32927-4305
US

IV. Provider business mailing address

805 CENTURY MEDICAL DR STE C
TITUSVILLE FL
32796-2100
US

V. Phone/Fax

Practice location:
  • Phone: 321-633-8660
  • Fax: 321-633-8617
Mailing address:
  • Phone: 321-268-6264
  • Fax: 321-268-6273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: KENT ANDREW BAILEY
Title or Position: VP FINANCE
Credential:
Phone: 321-268-6111