Healthcare Provider Details

I. General information

NPI: 1356744155
Provider Name (Legal Business Name): INDIAN RIVER PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 37TH PL STE 1N
VERO BEACH FL
32960-6502
US

IV. Provider business mailing address

840 37TH PL STE 1N
VERO BEACH FL
32960-6502
US

V. Phone/Fax

Practice location:
  • Phone: 772-978-9000
  • Fax: 772-978-9922
Mailing address:
  • Phone: 772-978-9000
  • Fax: 772-978-9922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME78173
License Number StateFL

VIII. Authorized Official

Name: MS. NANCY R SMITH
Title or Position: PRACTICE MANAGER
Credential:
Phone: 772-978-9000