Provider Demographics
NPI:1417948043
Name:PEDIATRICS IN BREVARD, P.A.
Entity Type:Organization
Organization Name:PEDIATRICS IN BREVARD, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOISELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-877-4438
Mailing Address - Street 1:699 W COCOA BEACH CSWY
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-3577
Mailing Address - Country:US
Mailing Address - Phone:321-784-5437
Mailing Address - Fax:321-799-1231
Practice Address - Street 1:699 W COCOA BEACH CSWY STE 401
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3562
Practice Address - Country:US
Practice Address - Phone:321-784-5437
Practice Address - Fax:321-799-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253255705Medicaid