Provider Demographics
NPI:1407182819
Name:ORTHOPAEDIC ASSOCIATES OF BREVARD LLC
Entity Type:Organization
Organization Name:ORTHOPAEDIC ASSOCIATES OF BREVARD LLC
Other - Org Name:ORTHOPAEDIC ASSOCIATES OF BREVARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MSO CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-449-4168
Mailing Address - Street 1:150 N SYKES CREEK PKWY
Mailing Address - Street 2:# 300
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3488
Mailing Address - Country:US
Mailing Address - Phone:321-449-4168
Mailing Address - Fax:321-449-4164
Practice Address - Street 1:1344 S APOLLO BLVD
Practice Address - Street 2:# 302
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3183
Practice Address - Country:US
Practice Address - Phone:321-309-2884
Practice Address - Fax:321-309-2807
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WUESTHOFF FAMILY PHYSICIANS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93258207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB70214Medicare UPIN