MEDICARE: SPACE COAST MEDICAL ASSOCIATES LLP

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	207RH0003X	Hematology & Oncology 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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	6992550001	OTHER	FL	PTAN
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558329581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPACE COAST MEDICAL ASSOCIATES LLP

Provider Business Mailing Address
First Line	:	490 N WASHINGTON AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32796-2871
Country	:	US
Telephone Number	:	311-268-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	490 N WASHINGTON AVE
Second Line	:
City	:	TITUSVILLE
State	:	FL
Zip	:	32796-2871
Country	:	US
Telephone Number	:	311-268-4200
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	RICHARD LEVINE
Credential	:	MD
Telephone Number	:	321-454-9001

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	07/29/2014

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