NPIMap

Organization Active NPI

Brevard Health Alliance Inc

  • Federally Qualified Health Center (FQHC)
  • Melbourne, FL
National Provider Identifier
1528115458
Registry record updated Feb 18, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
BREVARD HEALTH ALLIANCE INC
Practice address
17 Silver Palm Ave
Melbourne, FL 32901-3123
Phone
(321) 733-2021
Fax
(321) 727-0884
NPI assigned
Jan 4, 2007
Last updated
Feb 18, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 18, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Angela Craig
Title
Business Office Manager
Phone
(321) 952-9696

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X NU Primary

Addresses

Primary practice location

17 Silver Palm Ave
Melbourne, FL 32901-3123

Mailing address

17 Silver Palm Ave
Melbourne, FL 32901-3123
Phone (321) 733-2021

Other identifiers 1

IdentifierTypeStateIssuer
6886931-02MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050203000754 FL Part A Provider - Federally Qualified Health Center (FQHC) 0446201768 Practice locations: Melbourne, FL
O20151124000192 FL Part B Supplier - Clinic/Group Practice 0446201768 Receives reassigned benefits from 71 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Rockledge, FL; Titusville, FL; Palm Bay, FL; Melbourne, FL; Malabar, FL; Cocoa, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1528115458. Details of each certification follow.

Federally qualified health center certification: CCN 101977

Legal name
BREVARD HEALTH ALLIANCE INC
Doing business as
HICKORY CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 29, 2005
Last certification
Jul 29, 2005
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Apr 1, 2003 in FL
Enrollment address
17 Silver Palm Ave
Melbourne, FL 32901-3123

Other NPIs with the same Medicare PAC ID 17

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 17

Other NPIs on the same Medicare enrollment 10

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Brevard Health Alliance42 organizations share this tax ID, including this one

Other organizations with this tax ID 41

Organizations that report the same tax identification number in the National Provider Directory.

View all 41

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Brett Esrock Individual Corporate Director Aug 1, 2017
Barry Forbes Individual Corporate Director May 1, 2021
Colleen Browne Individual Corporate Director Mar 1, 2020
Erin Shea Individual Corporate Director Nov 1, 2018
Angela Craig Individual Corporate DirectorDirector of Billing Jan 15, 2010
W-2 Managing EmployeeAd;Director of Billing Jan 15, 2010
Richard a Helton Individual Corporate OfficerCeo Jun 1, 2016
Corporate DirectorCeo Jan 1, 2020
W-2 Managing EmployeeCeo Jun 1, 2016
Leigh Pettigrew Individual Corporate Director May 1, 2020
Keith Donald Individual Corporate Director Oct 1, 2018

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167868800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1392681600000",
    "number": "1528115458",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17 SILVER PALM AVE",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329013123",
            "telephone_number": "321-733-2021",
            "fax_number": "321-727-0884"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17 SILVER PALM AVE",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329013123",
            "telephone_number": "321-733-2021",
            "fax_number": "321-727-0884"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREVARD HEALTH ALLIANCE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-04",
        "last_updated": "2014-02-18",
        "status": "A",
        "authorized_official_last_name": "CRAIG",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_title_or_position": "BUSINESS OFFICE MANAGER",
        "authorized_official_telephone_number": "321-952-9696"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6886931-02",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Melbourne, FL

Sources for this page

Verify at the official NPI Registry.