1710270095 NPI number — BREVARD PATHOLOGY PA

Table of content: (NPI 1710270095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710270095 NPI number — BREVARD PATHOLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREVARD PATHOLOGY PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710270095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 SAN REMO AVE
Provider Second Line Business Mailing Address:
SUITE 280
Provider Business Mailing Address City Name:
CORAL GABLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33146-3043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-666-2427
Provider Business Mailing Address Fax Number:
305-666-1065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8745 N WICKHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940-5997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-666-2427
Provider Business Practice Location Address Fax Number:
305-667-0239
Provider Enumeration Date:
05/19/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BURENKO
Authorized Official First Name:
MARCO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-666-2427

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  ME 51687 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)