| Brevard Primary Care LLC | |
|
2328 Citadel Way Ste 103-319 Melbourne FL 32940-6459 | |
| (321) 757-1900 | |
| (866) 376-2481 |
| Full Name | Brevard Primary Care LLC |
|---|---|
| Speciality | Internal Medicine |
| Location | 2328 Citadel Way Ste 103-319, Melbourne, Florida |
| Authorized Official Name and Position | Bhavani M Puskur (PRACTICE OWNER) |
| Authorized Official Contact | 3219488555 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Brevard Primary Care LLC 2328 Citadel Way Ste 103-319 Melbourne FL 32940-6459 | Brevard Primary Care LLC 2328 Citadel Way Ste 103-319 Melbourne FL 32940-6459 Ph: (321) 757-1900 |
| NPI Number | 1376958462 |
|---|---|
| Provider Enumeration Date | 06/26/2014 |
| Last Update Date | 11/15/2024 |
| Certification Date | 11/15/2024 |
| Medicare PECOS PAC ID | 1153541669 |
|---|---|
| Medicare Enrollment ID | O20141006001145 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1376958462 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (NU) | Secondary |
| 207RI0200X | Internal Medicine - Infectious Disease | (NU) | Primary |
| Provider Name | Bhavani S Puskur |
|---|---|
| Provider Type | Practitioner - Infectious Disease |
| Provider Identifiers | NPI Number: 1760453427 PECOS PAC ID: 6800811779 Enrollment ID: I20051010000794 |
| Provider Name | Pushpa Chand Daliya |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1841761673 PECOS PAC ID: 6204162779 Enrollment ID: I20190723000980 |
| Provider Name | Amy Jagdmann |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1184268856 PECOS PAC ID: 6305224742 Enrollment ID: I20220526000039 |
| Provider Name | Kimberly Havens |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1336713965 PECOS PAC ID: 8224413687 Enrollment ID: I20220921001364 |
| Provider Name | Christina Ruthann Mattes |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1316719685 PECOS PAC ID: 4688021561 Enrollment ID: I20231114003781 |
| Provider Name | Eliza Charles |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1245098425 PECOS PAC ID: 4880162569 Enrollment ID: I20260512000299 |
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