Healthcare Provider Details

I. General information

NPI: 1629069240
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: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 FLORIDA AVE S STE A
ROCKLEDGE FL
32955-2142
US

IV. Provider business mailing address

134 S WOODS DR
ROCKLEDGE FL
32955-3262
US

V. Phone/Fax

Practice location:
  • Phone: 321-636-3066
  • Fax: 321-636-2545
Mailing address:
  • Phone: 321-636-3066
  • Fax: 321-636-2545

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: 321-877-4438