Healthcare Provider Details

I. General information

NPI: 1477513323
Provider Name (Legal Business Name): INDIAN RIVER PATHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6696 S US HIGHWAY 1
PORT ST LUCIE FL
34952-1423
US

IV. Provider business mailing address

PO BOX 881016
PORT ST LUCIE FL
34988-1016
US

V. Phone/Fax

Practice location:
  • Phone: 772-466-6651
  • Fax: 772-466-0662
Mailing address:
  • Phone: 772-466-6651
  • Fax: 772-466-0662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberME46694
License Number StateFL

VIII. Authorized Official

Name: DR. SHELLY M ROBINSON
Title or Position: COO AND BILLING MGR
Credential: PHD
Phone: 770-490-5009