Provider Demographics
NPI:1003807637
Name:PEDIATRICS IN BREVARD, P.A.
Entity Type:Organization
Organization Name:PEDIATRICS IN BREVARD, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOISELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-435-9800
Mailing Address - Street 1:134 S WOODS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8057 SPYGLASS HILL RD STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8565
Practice Address - Country:US
Practice Address - Phone:321-435-9800
Practice Address - Fax:321-435-9803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253255703Medicaid