Provider Demographics
NPI:1023041001
Name:LOGGERHEAD MEDICAL LLC
Entity Type:Organization
Organization Name:LOGGERHEAD MEDICAL LLC
Other - Org Name:ADVANCED PAIN AND NEUROMUSCULAR CONSULTANTS OF BREVARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-729-8223
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:307 E NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4576
Practice Address - Country:US
Practice Address - Phone:321-729-8223
Practice Address - Fax:321-729-6252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51048207LP2900X
FLME1051122081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275274302Medicaid
FL39339OtherBCBS
FL275274301Medicaid
FLDC0738OtherMEDICARE RAILROAD
FLDC0738OtherMEDICARE RAILROAD