NPIMap

Organization Active NPI

Brevard Health Alliance Inc

  • Federally Qualified Health Center (FQHC)
  • Cocoa, FL
National Provider Identifier
1962857417
Registry record updated Jun 17, 2016
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
7227 N US Highway 1
Cocoa, FL 32927-5020
Phone
(321) 877-2740
NPI assigned
May 3, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 17, 2016

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) 241-6834

Specialties & licenses 1

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

Addresses

Primary practice location

7227 N US Highway 1
Cocoa, FL 32927-5020

Mailing address

PO Box 1137
Melbourne, FL 32902-1137
Phone (321) 952-9696

Other names 1

  • Port St John Clinic Other name

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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
O20160621000001 FL Part A Provider - Federally Qualified Health Center (FQHC) 0446201768 Practice locations: Cocoa, FL

Federally qualified health center certification: CCN 681056

Legal name
BREVARD HEALTH ALLIANCE INC
Doing business as
PORT ST JOHN CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 21, 2016
Last certification
Jun 21, 2016
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 1, 2003 in FL
Enrollment address
7227 North US Highway 1
Cocoa, FL 32927-5020

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

Networks

  • HealthSun Health Plans Network

Ownership & related parties

All disclosed owners & managing parties 3

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

NameRoleSinceShare
Barry Forbes Individual Corporate Director Dec 29, 2021
Richard a Helton Individual Corporate OfficerCeo Jun 1, 2016
Corporate DirectorCeo Jun 1, 2016
W-2 Managing EmployeeCeo Jun 1, 2016
Synthia Michelle Doaks Individual Corporate Director May 27, 2022

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1462233600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1466121600000",
    "number": "1962857417",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1137",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329021137",
            "telephone_number": "321-952-9696",
            "fax_number": "321-952-7937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7227 N US HIGHWAY 1",
            "city": "COCOA",
            "state": "FL",
            "postal_code": "329275020",
            "telephone_number": "321-877-2740"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREVARD HEALTH ALLIANCE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-05-03",
        "last_updated": "2016-06-17",
        "status": "A",
        "authorized_official_last_name": "CRAIG",
        "authorized_official_first_name": "ANGELA",
        "authorized_official_title_or_position": "BUSINESS OFFICE MANAGER",
        "authorized_official_telephone_number": "321-241-6834"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Port St John Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Cocoa, FL

Sources for this page

Verify at the official NPI Registry.