Basic Information
| Provider Information | |||||||||
| NPI: | 1578846564 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRST CHOICE MEDICAL GROUP OF BREVARD LLC | ||||||||
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| OtherOrganizationName: | FIRST CHOICE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 709 S HARBOR CITY BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217252225 | ||||||||
| FaxNumber: | 3213080635 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 S COURTENAY PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329524977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217252225 | ||||||||
| FaxNumber: | 3213080635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2011 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3217250090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 002JP | 01 | FL | FLORIDA BLUE | OTHER |