Provider Demographics
NPI:1528063120
Name:BREVARD ORTHOPAEDICS, PA
Entity type:Organization
Organization Name:BREVARD ORTHOPAEDICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-884-2055
Mailing Address - Street 1:316 CHESTNUT ST
Mailing Address - Street 2:STE. 2
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-3010
Mailing Address - Country:US
Mailing Address - Phone:828-884-2055
Mailing Address - Fax:828-884-2834
Practice Address - Street 1:316 CHESTNUT ST
Practice Address - Street 2:STE. 2
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-3010
Practice Address - Country:US
Practice Address - Phone:828-884-2055
Practice Address - Fax:828-884-2834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016T3Medicaid
NC016T3OtherBCBS OF NC GROUP NUMBER
NC89016T3Medicaid