Provider Demographics
NPI:1467840710
Name:INDIAN RIVER MEDICAL OFFICE PA
Entity Type:Organization
Organization Name:INDIAN RIVER MEDICAL OFFICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:321-269-6530
Mailing Address - Street 1:3300 DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-1512
Mailing Address - Country:US
Mailing Address - Phone:321-269-6530
Mailing Address - Fax:321-269-2334
Practice Address - Street 1:3300 DAIRY RD
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-1512
Practice Address - Country:US
Practice Address - Phone:321-269-6530
Practice Address - Fax:321-269-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1189412363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty