Healthcare Provider Details

I. General information

NPI: 1710270095
Provider Name (Legal Business Name): BREVARD PATHOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8745 N WICKHAM RD
MELBOURNE FL
32940-5997
US

IV. Provider business mailing address

1500 SAN REMO AVE SUITE 280
CORAL GABLES FL
33146-3043
US

V. Phone/Fax

Practice location:
  • Phone: 305-666-2427
  • Fax: 305-667-0239
Mailing address:
  • Phone: 305-666-2427
  • Fax: 305-666-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME 51687
License Number StateFL

VIII. Authorized Official

Name: MARCO BURENKO
Title or Position: PRESIDENT
Credential: MD
Phone: 305-666-2427