Healthcare Provider Details

I. General information

NPI: 1497808828
Provider Name (Legal Business Name): BOERRE HENRIK BREVIK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3627 BRODHEAD RD
MONACA PA
15061-2681
US

IV. Provider business mailing address

3627 BRODHEAD RD
MONACA PA
15061-2681
US

V. Phone/Fax

Practice location:
  • Phone: 724-775-6012
  • Fax: 725-775-6010
Mailing address:
  • Phone: 724-775-6012
  • Fax: 725-775-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT006308L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier101857739
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier506243YC58
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMEDICARE
# 3
Identifier001456692
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK
# 4
Identifier322032
Identifier TypeOTHER
Identifier State
Identifier IssuerUPMC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: