Healthcare Provider Details

I. General information

NPI: 1700960143
Provider Name (Legal Business Name): HEMATOLOGY ONCOLOGY ASSOCIATES OF CENTRAL BREVARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 LONGWOOD AVE
ROCKLEDGE FL
32955-2827
US

IV. Provider business mailing address

107 LONGWOOD AVE
ROCKLEDGE FL
32955-2827
US

V. Phone/Fax

Practice location:
  • Phone: 321-636-2111
  • Fax: 321-636-9219
Mailing address:
  • Phone: 321-636-2111
  • Fax: 321-636-9219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: GAIL KNIGHT ERENTREICH
Title or Position: PRACTICE MANAGER
Credential:
Phone: 321-636-2111