1477509636 NPI number — VIERA SPORTS MEDICINE & ORTHOPEDIC CENTER, INC

Table of content: (NPI 1477509636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477509636 NPI number — VIERA SPORTS MEDICINE & ORTHOPEDIC CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIERA SPORTS MEDICINE & ORTHOPEDIC CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE ORTHOPEDIC & SPORTS MEDICINE CENTER OF BREVARD, INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477509636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8725 N. WICKHAM RD
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-434-9200
Provider Business Mailing Address Fax Number:
321-434-9202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8725 N. WICKHAM RD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-434-9200
Provider Business Practice Location Address Fax Number:
321-434-9202
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREENSPOON
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
321-434-9200

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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