Basic Information
| Provider Information | |||||||||
| NPI: | 1689112765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIAN RIVER HEALTH SERVICES INC | ||||||||
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| OtherOrganizationName: | PREMIER WOMENS HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 830270 | ||||||||
| Address2: | MSC #375 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352830270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725674311 | ||||||||
| FaxNumber: | 7727941450 | ||||||||
| Practice Location | |||||||||
| Address1: | 3450 11TH CT | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329605012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7727706801 | ||||||||
| FaxNumber: | 7727706802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2017 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | SUSI | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7725674311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 4029 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.