MEDICARE: PEDIATRICS IN BREVARD, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003807637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRICS IN BREVARD, P.A.

Provider Business Mailing Address
First Line	:	134 S WOODS DR
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-3262
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8057 SPYGLASS HILL RD STE 102
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32940-8565
Country	:	US
Telephone Number	:	321-435-9800
Fax Number	:	321-435-9803

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MELISSA LOISELLE
Credential	:
Telephone Number	:	321-435-9800

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	10/04/2022

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1538318589 — OSLER MEDICAL INC
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1003050352 — DONALD H. DEHAVEN MD
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1780926378 — WENDY B DEMKO NP-C
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