MEDICARE: INDIAN RIVER CARDIOLOGY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	ME0050599	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124069091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIAN RIVER CARDIOLOGY PA

Provider Business Mailing Address
First Line	:	3607 15TH AVE STE A
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-6513
Country	:	US
Telephone Number	:	772-562-8522
Fax Number	:	772-562-0317

Provider Business Practice Location Address
First Line	:	3607 15TH AVE STE A
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-6513
Country	:	US
Telephone Number	:	772-562-8522
Fax Number	:	772-562-0317

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARLES N CELANO
Credential	:	M.D.
Telephone Number	:	772-562-8522

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	09/28/2011

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