Provider Demographics
NPI:1548680531
Name:BREVARD PHYSICAL MEDICINE
Entity type:Organization
Organization Name:BREVARD PHYSICAL MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MADLENER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-751-5351
Mailing Address - Street 1:6420 3RD STREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-751-5351
Mailing Address - Fax:321-751-5370
Practice Address - Street 1:6420 3RD STREET
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-751-5351
Practice Address - Fax:321-751-5370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-17
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X, 363A00000X
FLME86688208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267338000Medicaid
FL267338000Medicaid