Provider Demographics
NPI:1558694034
Name:BREVARD SPECIALTY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:BREVARD SPECIALTY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-952-9800
Mailing Address - Street 1:95 BULLDOG BOULEVARD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3175
Mailing Address - Country:US
Mailing Address - Phone:321-952-9800
Mailing Address - Fax:321-952-7889
Practice Address - Street 1:95 BULLDOG BOULEVARD
Practice Address - Street 2:SUITE 104
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3175
Practice Address - Country:US
Practice Address - Phone:321-952-9800
Practice Address - Fax:321-952-7889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
FL846261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical