Provider Demographics
NPI:1578508966
Name:FAMILY MEDICAL CARE OF BREVARD
Entity Type:Organization
Organization Name:FAMILY MEDICAL CARE OF BREVARD
Other - Org Name:BREVARD MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:PAXSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-453-3638
Mailing Address - Street 1:258 FORTENBERRY RD
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3619
Mailing Address - Country:US
Mailing Address - Phone:321-453-3638
Mailing Address - Fax:321-452-1185
Practice Address - Street 1:258 FORTENBERRY RD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3619
Practice Address - Country:US
Practice Address - Phone:321-453-3638
Practice Address - Fax:321-452-1185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID #