Provider Demographics
NPI:1699881664
Name:BREVARD ANESTHESIA SERVICES PA
Entity type:Organization
Organization Name:BREVARD ANESTHESIA SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHENA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-723-4723
Mailing Address - Street 1:1304 OAK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3111
Mailing Address - Country:US
Mailing Address - Phone:321-723-4723
Mailing Address - Fax:321-727-1448
Practice Address - Street 1:1304 OAK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3111
Practice Address - Country:US
Practice Address - Phone:321-723-4723
Practice Address - Fax:321-727-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL163W00000X, 207LP2900X, 363L00000X, 367500000X
207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0841OtherRRMCR
FL00762OtherBCBSFL
FL059707400Medicaid
FLK0841OtherRRMCR