Provider Demographics
NPI:1912981622
Name:BREVARD SURGICAL ASSOCIATES,PA
Entity Type:Organization
Organization Name:BREVARD SURGICAL ASSOCIATES,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOEKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-884-2198
Mailing Address - Street 1:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-1689
Mailing Address - Country:US
Mailing Address - Phone:828-884-2198
Mailing Address - Fax:828-862-5328
Practice Address - Street 1:120 S JOHNSON ST
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-3749
Practice Address - Country:US
Practice Address - Phone:828-884-2198
Practice Address - Fax:828-862-5328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890175MMedicaid
NC0175MOtherBCBS
NC890175MMedicaid
NC2312237Medicare PIN