Provider Demographics
NPI:1215254073
Name:BREVARD HEALTH CENTER PL
Entity type:Organization
Organization Name:BREVARD HEALTH CENTER PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:APARNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BALAJI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-215-6899
Mailing Address - Street 1:298 MICHIGAN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3104
Mailing Address - Country:US
Mailing Address - Phone:321-215-6899
Mailing Address - Fax:321-215-6789
Practice Address - Street 1:298 MICHIGAN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3104
Practice Address - Country:US
Practice Address - Phone:321-215-6899
Practice Address - Fax:321-215-6789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110199177OtherRAIL ROAD MEDICARE
FL257850600Medicaid
FL257850600Medicaid