Provider Demographics
NPI:1013176940
Name:CANCER CARE CENTERS OF BREVARD INC
Entity Type:Organization
Organization Name:CANCER CARE CENTERS OF BREVARD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SILAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-952-0898
Mailing Address - Street 1:PO BOX 534595
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-4595
Mailing Address - Country:US
Mailing Address - Phone:321-952-0898
Mailing Address - Fax:321-952-6296
Practice Address - Street 1:13050 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3733
Practice Address - Country:US
Practice Address - Phone:321-952-0898
Practice Address - Fax:321-952-6296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCL7578OtherRR MEDICARE
FL372996605Medicaid
FLCL7578OtherRR MEDICARE