Provider Demographics
NPI:1942390182
Name:INDIAN RIVER FOOT & ANKLE, PA
Entity Type:Organization
Organization Name:INDIAN RIVER FOOT & ANKLE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAILE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
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:2006-10-16
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390266800Medicaid
FL390266800Medicaid
FL1044850001Medicare NSC
FL33908Medicare PIN