Healthcare Provider Details

I. General information

NPI: 1194704544
Provider Name (Legal Business Name): BREVARD NEUROLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 ROCKLEDGE BLVD UNIT 101
ROCKLEDGE FL
32955
US

IV. Provider business mailing address

1910 ROCKLEDGE BLVD UNIT 101
ROCKLEDGE FL
32955
US

V. Phone/Fax

Practice location:
  • Phone: 321-636-8366
  • Fax: 321-636-3985
Mailing address:
  • Phone: 321-636-8366
  • Fax: 321-636-3985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberME58732
License Number StateFL

VIII. Authorized Official

Name: MR. WASIM NIAZI
Title or Position: CORPORATE OFFICE
Credential: MD
Phone: 321-636-8366