Basic Information
| Provider Information | |||||||||
| NPI: | 1710270095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BREVARD PATHOLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 SAN REMO AVE | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331463043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056662427 | ||||||||
| FaxNumber: | 3056661065 | ||||||||
| Practice Location | |||||||||
| Address1: | 8745 N WICKHAM RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329405997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056662427 | ||||||||
| FaxNumber: | 3056670239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2011 | ||||||||
| LastUpdateDate: | 05/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | BURENKO | ||||||||
| AuthorizedOfficialFirstName: | MARCO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3056662427 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | ME 51687 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.