Provider Demographics
NPI:1679622120
Name:BREVARD HEALTH ALLIANCE INC
Entity type:Organization
Organization Name:BREVARD HEALTH ALLIANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
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:321-241-6800
Mailing Address - Street 1:5270 BABCOCK ST NE # ST1
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-8630
Mailing Address - Country:US
Mailing Address - Phone:321-722-5959
Mailing Address - Fax:
Practice Address - Street 1:5270 BABCOCK ST NE # ST1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-8630
Practice Address - Country:US
Practice Address - Phone:321-722-5959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6886931-01Medicaid
FL6886931-01Medicaid