Provider Demographics
NPI:1003029786
Name:BREVARD NEPHROLOGY GROUP PA
Entity type:Organization
Organization Name:BREVARD NEPHROLOGY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:K
Authorized Official - Last Name:WANICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-453-5326
Mailing Address - Street 1:245 S COURTENAY PARKWAY
Mailing Address - Street 2:BLDG B
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952
Mailing Address - Country:US
Mailing Address - Phone:321-453-5326
Mailing Address - Fax:321-452-8507
Practice Address - Street 1:245 S COURTENAY PARKWAY
Practice Address - Street 2:BLDG B
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952
Practice Address - Country:US
Practice Address - Phone:321-453-5326
Practice Address - Fax:321-452-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45829Medicare ID - Type Unspecified