Provider Demographics
NPI:1922274398
Name:GI ASSOCIATES OF BREVARD
Entity Type:Organization
Organization Name:GI ASSOCIATES OF BREVARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MSO CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-449-4168
Mailing Address - Street 1:150 N SYKES CREEK PKWY
Mailing Address - Street 2:#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 1:1004 BEVERLY DR
Practice Address - Street 2:SUITE B
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2851
Practice Address - Country:US
Practice Address - Phone:321-637-7655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49690207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE21362Medicare UPIN