Provider Demographics
NPI:1336444637
Name:BREVARD HEALTH ALLIANCE
Entity type:Organization
Organization Name:BREVARD HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-952-9696
Mailing Address - Street 1:500 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2759
Mailing Address - Country:US
Mailing Address - Phone:321-264-5496
Mailing Address - Fax:321-268-3357
Practice Address - Street 1:500 N WASHINGTON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2759
Practice Address - Country:US
Practice Address - Phone:321-264-5496
Practice Address - Fax:321-268-3357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6886931-13Medicaid