Basic Information
| Provider Information | |||||||||
| NPI: | 1285255810 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADM ORTHOPAEDICS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BREVARD ORTHOPAEDIC SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 930 S HARBOR CITY BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213457579 | ||||||||
| FaxNumber: | 3213272494 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 S HARBOR CITY BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213457579 | ||||||||
| FaxNumber: | 3213272494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2020 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WADE | ||||||||
| AuthorizedOfficialFirstName: | ALLISON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 7726311741 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | MX816 | 01 | FL | MEDICARE | OTHER |