Basic Information
| Provider Information | |||||||||
| NPI: | 1962119370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BREVARD HEALTH ALLIANCE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1137 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329021137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219529696 | ||||||||
| FaxNumber: | 3219527937 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329017121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212416800 | ||||||||
| FaxNumber: | 3212416888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2022 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING | ||||||||
| AuthorizedOfficialTelephone: | 3216983446 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 6886931-33 | 05 | FL | MEDICAID |