Provider Demographics
NPI:1801062310
Name:INDIAN RIVER MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:INDIAN RIVER MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER/CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONGVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-636-7416
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 1:1190 37TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6507
Practice Address - Country:US
Practice Address - Phone:772-567-4311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIAN RIVER MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-05
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4029273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL309OtherBLUE CROSS
FL010104400Medicaid
FL010104400Medicaid