Basic Information
| Provider Information | |||||||||
| NPI: | 1225682784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BREVARD GERIATRICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 E NEW HAVEN AVE SUITE 11 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217244545 | ||||||||
| FaxNumber: | 3217284168 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 E NEW HAVEN AVE SUITE 11 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217244545 | ||||||||
| FaxNumber: | 3217284168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2019 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | POTOMSKI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3214465893 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 067596200 | 05 | FL | MEDICAID |