Provider Demographics
NPI:1679912497
Name:BREVIK, JEANNINE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNINE
Middle Name:MARIE
Last Name:BREVIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12351 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12351 PERRY HWY
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8344
Practice Address - Country:US
Practice Address - Phone:724-939-3673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-15
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD459364208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103243829Medicaid
PA13963611OtherCAQH
PA103243829Medicaid