Provider Demographics
NPI:1891719399
Name:WUESTHOFF BREVARD CARDIOLOGY GROUP
Entity Type:Organization
Organization Name:WUESTHOFF BREVARD CARDIOLOGY GROUP
Other - Org Name:BREVARD CARDIOLOGY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-636-2211
Mailing Address - Street 1:150 N SYKES CREEK PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3488
Mailing Address - Country:US
Mailing Address - Phone:321-449-4168
Mailing Address - Fax:321-449-4164
Practice Address - Street 1:150 N SYKES CREEK PKWY
Practice Address - Street 2:STE 300
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3488
Practice Address - Country:US
Practice Address - Phone:321-449-4168
Practice Address - Fax:321-449-4164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTIN
FL=========OtherTIN