Provider Demographics
NPI:1194704544
Name:BREVARD NEUROLOGY ASSOCIATES PA
Entity type:Organization
Organization Name:BREVARD NEUROLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICE
Authorized Official - Prefix:MR
Authorized Official - First Name:WASIM
Authorized Official - Middle Name:
Authorized Official - Last Name:NIAZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-636-8366
Mailing Address - Street 1:1910 ROCKLEDGE BLVD
Mailing Address - Street 2:UNIT 101
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-636-8366
Mailing Address - Fax:321-636-3985
Practice Address - Street 1:1910 ROCKLEDGE BLVD
Practice Address - Street 2:UNIT 101
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-636-8366
Practice Address - Fax:321-636-3985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58732261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0500148OtherUNITED
FL377423600Medicaid
FL5395693OtherAETNA GRP
FL26705Other26705
FL45249OtherBC BS GRP
FL4657556OtherAETNA
FL130016629OtherMEDICARE RR
FLK1528Medicare ID - Type UnspecifiedGROUP
FL4657556OtherAETNA
FL26705YMedicare ID - Type Unspecified