Provider Demographics
NPI:1710216262
Name:BREVARD INTERNAL MEDICINE & WALK-IN CLINIC
Entity Type:Organization
Organization Name:BREVARD INTERNAL MEDICINE & WALK-IN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARAVIND
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-622-8626
Mailing Address - Street 1:PO BOX 411685
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32941-1685
Mailing Address - Country:US
Mailing Address - Phone:321-622-8626
Mailing Address - Fax:321-622-8627
Practice Address - Street 1:2795 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3705
Practice Address - Country:US
Practice Address - Phone:321-622-8626
Practice Address - Fax:321-622-8627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97764261QP2300X
FLARNP 2107012261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD979ZMedicare PIN
NYI07145Medicare UPIN