MEDICARE: ROBERT C UDELL DO LLC

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	207R00000X	Internal Medicine Physician	OS7144	FL

General Provider Information

NPI Number	:	1386688257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERT C UDELL DO LLC

Provider Business Mailing Address
First Line	:	150 N SYKES CREEK PKWY
Second Line	:	# 300
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-3488
Country	:	US
Telephone Number	:	321-449-4168
Fax Number	:	321-449-4164

Provider Business Practice Location Address
First Line	:	1980 N ATLANTIC AVE
Second Line	:	SUITE 1010
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-5213
Country	:	US
Telephone Number	:	321-868-0360
Fax Number	:	321-799-4968

Authorized Official
Title or Position	:	MSO CREDENTIALING COORDINATOR
Name	:	SANDI LAROCHE
Credential	:
Telephone Number	:	321-449-4168

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	08/28/2009

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