Provider Demographics
NPI:1497808828
Name:BREVIK, BOERRE HENRIK (PT)
Entity Type:Individual
Prefix:MR
First Name:BOERRE
Middle Name:HENRIK
Last Name:BREVIK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 BRODHEAD RD
Mailing Address - Street 2:
Mailing Address - City:MONACA
Mailing Address - State:PA
Mailing Address - Zip Code:15061-2681
Mailing Address - Country:US
Mailing Address - Phone:724-775-6012
Mailing Address - Fax:725-775-6010
Practice Address - Street 1:3627 BRODHEAD RD
Practice Address - Street 2:
Practice Address - City:MONACA
Practice Address - State:PA
Practice Address - Zip Code:15061-2681
Practice Address - Country:US
Practice Address - Phone:724-775-6012
Practice Address - Fax:725-775-6010
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT006308L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101857739Medicaid
PA506243YC58OtherMEDICARE
PA001456692OtherHIGHMARK
322032OtherUPMC
PA506243YC58OtherMEDICARE