NPIMap

Organization Active NPI

Brevard Health Alliance Inc

  • Federally Qualified Health Center (FQHC)
  • Malabar, FL
National Provider Identifier
1790056877
Registry record updated Apr 4, 2013
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
775 Malabar Rd
Malabar, FL 32950-3120
Phone
(321) 722-8435
Fax
(321) 722-8486
NPI assigned
Jan 20, 2012
Last updated
Apr 4, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 4, 2013

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 Primary

Addresses

Primary practice location

775 Malabar Rd
Malabar, FL 32950-3120

Mailing address

775 Malabar Rd
Malabar, FL 32950-3120
Phone (321) 722-8435

Other identifiers 1

IdentifierTypeStateIssuer
6886931-14MedicaidFL

Other names 1

  • Malabar Clinic Other name

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20120524000658 FL Part A Provider - Federally Qualified Health Center (FQHC) 0446201768 Practice locations: Malabar, 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 1790056877. Details of each certification follow.

Federally qualified health center certification: CCN 101090

Legal name
BREVARD HEALTH ALLIANCE INC
Doing business as
BREVARD HEALTH ALLIANCE
Organization structure
OtherNon-profit
Incorporated
Apr 1, 2003 in FL
Enrollment address
775 Malabar Rd
Malabar, FL 32950-3112

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
The Brevard Health Alliance Inc42 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

Locations

775 Malabar Rd
Ste 105
Malabar, FL 32950
Phone (321) 733-0642

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Robert Santiago Individual Corporate DirectorBoard Member Aug 1, 2019
Lena Marie Knapp Individual Corporate DirectorBoard Member Nov 1, 2018
Brett Esrock Individual Corporate DirectorBoard Member Aug 1, 2017
Barry Forbes Individual Corporate DirectorBoard Member Dec 1, 2021
Colleen Browne Individual Corporate DirectorBoard Member Mar 1, 2020
Joseph Flynn Individual Corporate DirectorBoard Member Jan 1, 2023
Erin Shea Individual Corporate DirectorBoard Member Nov 1, 2018
Kevin Hill Individual Corporate DirectorBoard Member Feb 1, 2011
Richard a Helton Individual Corporate OfficerCeo Jun 1, 2016
W-2 Managing EmployeeCeo Jun 1, 2016
Leigh Pettigrew Individual Corporate DirectorBoard Member Feb 1, 2022
Keith Donald Individual Corporate DirectorBoard Member Oct 1, 2018
Synthia Michelle Doaks Individual Corporate DirectorBoard Member May 1, 2022

Practitioners & affiliated clinicians

Practitioners 8

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": "1327017600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1365033600000",
    "number": "1790056877",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "775 MALABAR RD",
            "city": "MALABAR",
            "state": "FL",
            "postal_code": "329503120",
            "telephone_number": "321-722-8435",
            "fax_number": "321-722-8486"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "775 MALABAR RD",
            "city": "MALABAR",
            "state": "FL",
            "postal_code": "329503120",
            "telephone_number": "321-722-8435",
            "fax_number": "321-722-8486"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREVARD HEALTH ALLIANCE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-01-20",
        "last_updated": "2013-04-04",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6886931-14",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Malabar Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Malabar, FL

Sources for this page

Verify at the official NPI Registry.