Basic Information
| Provider Information | |||||||||
| NPI: | 1801062310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIAN RIVER MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BEHAVIORAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 36TH ST | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329604862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725674311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1190 37TH ST | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329606507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725674311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | SUSI | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7725674311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INDIAN RIVER MEMORIAL HOSPITAL, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 4029 | FL | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 010104400 | 05 | FL | MEDICAID | 309 | 01 | FL | BLUE CROSS | OTHER |