Provider Demographics
NPI:1861400103
Name:MEDICAL ASSOCIATES OF BREVARD LLC
Entity type:Organization
Organization Name:MEDICAL ASSOCIATES OF BREVARD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BESSETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-253-2900
Mailing Address - Street 1:PO BOX 361095
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32936-1095
Mailing Address - Country:US
Mailing Address - Phone:321-253-2900
Mailing Address - Fax:321-435-0100
Practice Address - Street 1:2200 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935
Practice Address - Country:US
Practice Address - Phone:321-253-2900
Practice Address - Fax:321-435-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250155400Medicaid
FL40462Medicare PIN