Healthcare Provider Details

I. General information

NPI: 1497714380
Provider Name (Legal Business Name): INDIAN RIVER MEMORIAL HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 36TH ST
VERO BEACH FL
32960-4862
US

IV. Provider business mailing address

1000 36TH ST
VERO BEACH FL
32960-4862
US

V. Phone/Fax

Practice location:
  • Phone: 772-567-4311
  • Fax:
Mailing address:
  • Phone: 772-567-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4029
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4029
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4029
License Number StateFL

VIII. Authorized Official

Name: TIM LONGVILLE
Title or Position: CHIEF ACCOUNTING OFFICER AND CONTRO
Credential:
Phone: 216-636-7416