Provider Demographics
NPI:1164443859
Name:INDIAN RIVER PODIATRY, PA
Entity Type:Organization
Organization Name:INDIAN RIVER PODIATRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:772-569-0081
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32961-0099
Mailing Address - Country:US
Mailing Address - Phone:772-569-0081
Mailing Address - Fax:772-569-0819
Practice Address - Street 1:1880 37TH STREET, SUITE 4
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4502
Practice Address - Country:US
Practice Address - Phone:772-569-0081
Practice Address - Fax:772-569-0819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP02624213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65519AMedicare ID - Type Unspecified
FLU65728Medicare UPIN