Provider Demographics
NPI:1609408996
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:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
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:
Practice Address - Street 1:1515 US HIGHWAY 1 STE 204
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1612
Practice Address - Country:US
Practice Address - Phone:772-569-0081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIAN RIVER PODIATRY, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty