Provider Demographics
NPI:1295832343
Name:OB/GYN SPECIALISTS OF BREVARD, LLC
Entity Type:Organization
Organization Name:OB/GYN SPECIALISTS OF BREVARD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-733-2201
Mailing Address - Street 1:1555 W NASA BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2640
Mailing Address - Country:US
Mailing Address - Phone:321-733-2201
Mailing Address - Fax:321-733-2202
Practice Address - Street 1:1555 W NASA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2640
Practice Address - Country:US
Practice Address - Phone:321-733-2201
Practice Address - Fax:321-733-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259101400Medicaid
FLH21823Medicare UPIN
FL35683XMedicare PIN