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General NPI Number Information
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NPI Number | 1003029786
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Entity Type | Organization
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Legal Business Name | BREVARD NEPHROLOGY GROUP PA
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 11/14/2012
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Provider Practice Location Address
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Address Line | 245 S COURTENAY PARKWAY BLDG B
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City | MERRITT ISLAND
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State | FL
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Zip | 32952
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Country | US
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Telephone | 321-453-5326
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Fax | 321-452-8507
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Provider Business Mailing Address
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Address Line | 245 S COURTENAY PARKWAY BLDG B
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City | MERRITT ISLAND
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State | FL
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Zip | 32952
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Country | US
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Telephone | 321-453-5326
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Fax | 321-452-8507
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Authorized Official
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Title or Position | PHYSICIAN
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Name | CHARLES K WANICH
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Credential | MD
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Telephone | 321-453-5326
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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