Provider Demographics
NPI:1558329581
Name:SPACE COAST MEDICAL ASSOCIATES LLP
Entity Type:Organization
Organization Name:SPACE COAST MEDICAL ASSOCIATES LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-454-9001
Mailing Address - Street 1:490 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2871
Mailing Address - Country:US
Mailing Address - Phone:311-268-4200
Mailing Address - Fax:
Practice Address - Street 1:490 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2871
Practice Address - Country:US
Practice Address - Phone:311-268-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253792307Medicaid
FL253792301Medicaid
FL253792305Medicaid
FL6992550001OtherPTAN
FL253792304Medicaid
FL253792300Medicaid
FL253792303Medicaid
FL40680AMedicare PIN
FL253792301Medicaid
FL253792303Medicaid
40680FMedicare PIN