Basic Information
| Provider Information | |||||||||
| NPI: | 1336444637 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BREVARD HEALTH ALLIANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 N WASHINGTON AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327962759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212645496 | ||||||||
| FaxNumber: | 3212683357 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N WASHINGTON AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | TITUSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327962759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212645496 | ||||||||
| FaxNumber: | 3212683357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2011 | ||||||||
| LastUpdateDate: | 01/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3219529696 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 6886931-13 | 05 | FL | MEDICAID |