Provider Demographics
NPI:1255210530
Name:BRAINGEVITYMD
Entity type:Organization
Organization Name:BRAINGEVITYMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAZEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-820-1520
Mailing Address - Street 1:9220 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-5422
Mailing Address - Country:US
Mailing Address - Phone:813-820-1520
Mailing Address - Fax:
Practice Address - Street 1:9220 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-5422
Practice Address - Country:US
Practice Address - Phone:813-820-1520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center