Provider Demographics
NPI:1689112765
Name:INDIAN RIVER HEALTH SERVICES INC
Entity Type:Organization
Organization Name:INDIAN RIVER HEALTH SERVICES INC
Other - Org Name:PREMIER WOMENS HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-567-4311
Mailing Address - Street 1:PO BOX 830270
Mailing Address - Street 2:MSC #375
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283-0270
Mailing Address - Country:US
Mailing Address - Phone:772-567-4311
Mailing Address - Fax:772-794-1450
Practice Address - Street 1:3450 11TH CT
Practice Address - Street 2:SUITE 304
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5012
Practice Address - Country:US
Practice Address - Phone:772-770-6801
Practice Address - Fax:772-770-6802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4029207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty