Provider Demographics
NPI:1801855069
Name:INDIAN RIVER MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:INDIAN RIVER MEMORIAL HOSPITAL INC
Other - Org Name:PARTNERS IN WOMEN'S HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
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 1:1000 36TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4862
Mailing Address - Country:US
Mailing Address - Phone:772-567-4311
Mailing Address - Fax:
Practice Address - Street 1:787 37TH ST
Practice Address - Street 2:SUITE E-170
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7305
Practice Address - Country:US
Practice Address - Phone:772-770-6116
Practice Address - Fax:772-564-6120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4029207V00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21923OtherBLUE CROSS
FL98912Medicare PIN
FL98912Medicare ID - Type Unspecified