Provider Demographics
NPI:1326147901
Name:SPACE COAST RHEUMATOLOGY & ARTHRITIS CENTER PA
Entity Type:Organization
Organization Name:SPACE COAST RHEUMATOLOGY & ARTHRITIS CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SALACH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:321-759-8640
Mailing Address - Street 1:475 INDIAN BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953
Mailing Address - Country:US
Mailing Address - Phone:321-759-8640
Mailing Address - Fax:
Practice Address - Street 1:40 FORTENBERRY ROAD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952
Practice Address - Country:US
Practice Address - Phone:321-453-0779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 6549207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2821Medicare ID - Type Unspecified