MEDICARE: BREVARD MEDICAL DERMATOLOGY, PA

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	207N00000X	Dermatology 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	:	1649676669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREVARD MEDICAL DERMATOLOGY, PA

Provider Business Mailing Address
First Line	:	7960 N. WICKHAM ROAD
Second Line	:	SUITE 103
City	:	MELBOURNE
State	:	FL
Zip	:	32940-8096
Country	:	US
Telephone Number	:	321-428-4737
Fax Number	:	321-241-6457

Provider Business Practice Location Address
First Line	:	7960 N. WICKHAM ROAD
Second Line	:	SUITE 103
City	:	MELBOURNE
State	:	FL
Zip	:	32940-8096
Country	:	US
Telephone Number	:	321-428-4737
Fax Number	:	321-241-6457

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL SPICER
Credential	:	MD
Telephone Number	:	321-428-4737

Provider Enumeration Date	:	11/18/2014
Last Update Date	:	02/21/2020

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