Provider Demographics
NPI:1598065732
Name:INDIAN RIVER REHABILITATION MEDICINE CLINIC P A
Entity Type:Organization
Organization Name:INDIAN RIVER REHABILITATION MEDICINE CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IHEONU
Authorized Official - Middle Name:USOUWA
Authorized Official - Last Name:ORIAKU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-643-4208
Mailing Address - Street 1:P O BOX 2692
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32961-2692
Mailing Address - Country:US
Mailing Address - Phone:772-778-1603
Mailing Address - Fax:772-231-8470
Practice Address - Street 1:631 17TH STREET
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5518
Practice Address - Country:US
Practice Address - Phone:772-778-1603
Practice Address - Fax:772-231-8470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79198207P00000X, 207Q00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259802700Medicaid
FL49280OtherMEDICARE
FLH05066Medicare UPIN