Healthcare Provider Details

I. General information

NPI: 1801855069
Provider Name (Legal Business Name): INDIAN RIVER MEMORIAL HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 37TH ST SUITE E-170
VERO BEACH FL
32960-7305
US

IV. Provider business mailing address

1000 36TH ST
VERO BEACH FL
32960-4862
US

V. Phone/Fax

Practice location:
  • Phone: 772-770-6116
  • Fax: 772-564-6120
Mailing address:
  • Phone: 772-567-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4029
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number4029
License Number StateFL

VIII. Authorized Official

Name: JEFFREY L SUSI
Title or Position: CEO/PRESIDENT
Credential:
Phone: 772-567-4311