Basic Information
| Provider Information | |||||||||
| NPI: | 1629069240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRICS IN BREVARD, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 S WOODS DR | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216363066 | ||||||||
| FaxNumber: | 3216362545 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 S WOODS DR | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216363066 | ||||||||
| FaxNumber: | 3216362545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | LOISELLE | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3218774438 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 253255701 | 05 | FL | MEDICAID | 253555703 | 05 | FL | MEDICAID | 253255700 | 05 | FL | MEDICAID | 253255705 | 05 | FL | MEDICAID |