Provider Demographics
NPI:1578846564
Name:FIRST CHOICE MEDICAL GROUP OF BREVARD LLC
Entity type:Organization
Organization Name:FIRST CHOICE MEDICAL GROUP OF BREVARD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-725-0090
Mailing Address - Street 1:709 S HARBOR CITY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1938
Mailing Address - Country:US
Mailing Address - Phone:321-725-2225
Mailing Address - Fax:321-308-0635
Practice Address - Street 1:650 S COURTENAY PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4977
Practice Address - Country:US
Practice Address - Phone:321-725-2225
Practice Address - Fax:321-308-0635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002JPOtherFLORIDA BLUE
FL6707110001Medicare NSC