Healthcare Provider Details

I. General information

NPI: 1063578995
Provider Name (Legal Business Name): IRINA S MEZHERITSKIY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 S HICKORY ST HOLMES REGIONAL MEDICAL CENTER/RADIOLOGY
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

PO BOX 2400
MELBOURNE FL
32902-2400
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-7313
  • Fax: 321-434-7238
Mailing address:
  • Phone: 321-434-4600
  • Fax: 321-259-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMT188713
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME106422
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: