Provider Demographics
NPI:1235211327
Name:BREVARD KIDNEY & HYPERTENSION INC
Entity Type:Organization
Organization Name:BREVARD KIDNEY & HYPERTENSION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUKON
Authorized Official - Middle Name:K
Authorized Official - Last Name:WANICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-452-0020
Mailing Address - Street 1:245 S COURTENAY PKWY
Mailing Address - Street 2:BLDG A
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952
Mailing Address - Country:US
Mailing Address - Phone:321-452-0020
Mailing Address - Fax:321-453-4366
Practice Address - Street 1:245 S COURTENAY PKWY
Practice Address - Street 2:BLDG A
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952
Practice Address - Country:US
Practice Address - Phone:321-452-0020
Practice Address - Fax:321-453-4366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV78OtherBCBS OF FL
102553Medicare ID - Type Unspecified