Provider Demographics
NPI:1538471487
Name:PODIATRY ASSOCIATES OF INDIAN RIVER COUNTY, LLC
Entity Type:Organization
Organization Name:PODIATRY ASSOCIATES OF INDIAN RIVER COUNTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MD
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JERRY
Authorized Official - Last Name:HAILE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-589-3110
Mailing Address - Street 1:1424 US HIGHWAY 1
Mailing Address - Street 2:SUITE A
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-1619
Mailing Address - Country:US
Mailing Address - Phone:772-589-3110
Mailing Address - Fax:772-388-1929
Practice Address - Street 1:1424 US HIGHWAY 1
Practice Address - Street 2:SUITE A
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1619
Practice Address - Country:US
Practice Address - Phone:772-589-3110
Practice Address - Fax:772-388-1929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty