Provider Demographics
NPI:1184806630
Name:BREVARD VASCULAR ASSOCIATES LLC
Entity type:Organization
Organization Name:BREVARD VASCULAR ASSOCIATES LLC
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:SUITE 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 D
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2851
Practice Address - Country:US
Practice Address - Phone:321-637-4710
Practice Address - Fax:321-637-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME915092086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH24893Medicare UPIN