Provider Demographics
NPI:1225682784
Name:BREVARD GERIATRICS, LLC
Entity Type:Organization
Organization Name:BREVARD GERIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTOMSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-446-5893
Mailing Address - Street 1:720 E NEW HAVEN AVE SUITE 11
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5474
Mailing Address - Country:US
Mailing Address - Phone:321-724-4545
Mailing Address - Fax:321-728-4168
Practice Address - Street 1:720 E NEW HAVEN AVE SUITE 11
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5474
Practice Address - Country:US
Practice Address - Phone:321-724-4545
Practice Address - Fax:321-728-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067596200Medicaid