Basic Information
| Provider Information | |||||||||
| NPI: | 1932217759 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL BREVARD RADIOLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 881839 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349881839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278963134 | ||||||||
| FaxNumber: | 7706213181 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 W COCOA BEACH CSWY | ||||||||
| Address2: | |||||||||
| City: | COCOA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329313585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217997192 | ||||||||
| FaxNumber: | 7702374866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 02/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | HILLEREN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3217997192 | ||||||||
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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 | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 39812 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | CA4481 | 01 | FL | RR MEDICARE | OTHER | 058771100 | 05 | FL | MEDICAID |