1194704544 NPI number — BREVARD NEUROLOGY ASSOCIATES PA

Table of content: (NPI 1194704544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194704544 NPI number — BREVARD NEUROLOGY ASSOCIATES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREVARD NEUROLOGY ASSOCIATES PA
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:
Provider Other Organization Name Type Code:
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:
1194704544
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 ROCKLEDGE BLVD
Provider Second Line Business Mailing Address:
UNIT 101
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-636-8366
Provider Business Mailing Address Fax Number:
321-636-3985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 ROCKLEDGE BLVD
Provider Second Line Business Practice Location Address:
UNIT 101
Provider Business Practice Location Address City Name:
ROCKLEDGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-636-8366
Provider Business Practice Location Address Fax Number:
321-636-3985
Provider Enumeration Date:
01/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NIAZI
Authorized Official First Name:
WASIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CORPORATE OFFICE
Authorized Official Telephone Number:
321-636-8366

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  ME58732 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0500148 . This is a "UNITED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 377423600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5395693 . This is a "AETNA GRP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 26705 . This is a "26705" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 45249 . This is a "BC BS GRP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4657556 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 130016629 . This is a "MEDICARE RR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 009746300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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