Basic Information
| Provider Information | |||||||||
| NPI: | 1538582366 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL ASSOCIATES OF BREVARD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 S WICKHAM RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WEST MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329041170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213085060 | ||||||||
| FaxNumber: | 3213085069 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 S WICKHAM RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | WEST MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329041170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213085060 | ||||||||
| FaxNumber: | 3213085069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2014 | ||||||||
| LastUpdateDate: | 06/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | GADODIA | ||||||||
| AuthorizedOfficialFirstName: | GOPAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3212532900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.