Provider Demographics
NPI:1710270095
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:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:
Authorized Official - Last Name:BURENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-666-2427
Mailing Address - Street 1:1500 SAN REMO AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-3043
Mailing Address - Country:US
Mailing Address - Phone:305-666-2427
Mailing Address - Fax:305-666-1065
Practice Address - Street 1:8745 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-5997
Practice Address - Country:US
Practice Address - Phone:305-666-2427
Practice Address - Fax:305-667-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 51687207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty