Provider Demographics
NPI:1619947835
Name:BREVARD PATHOLOGY PA
Entity Type:Organization
Organization Name:BREVARD PATHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:
Authorized Official - Last Name:BURENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-799-7123
Mailing Address - Street 1:657 BREVARD AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922
Mailing Address - Country:US
Mailing Address - Phone:321-632-6880
Mailing Address - Fax:
Practice Address - Street 1:699 W COCOA BCH CSWY
Practice Address - Street 2:STE 203
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931
Practice Address - Country:US
Practice Address - Phone:321-799-7123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94943Medicare PIN