Basic Information
| Provider Information | |||||||||
| NPI: | 1932362555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIAN RIVER MEMORIAL HOSPITAL INC | ||||||||
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| OtherOrganizationName: | INDEPENDENT CLINICAL LABORATORY | ||||||||
| 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: | 1000 36TH ST | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329604862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725674311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | SUSI | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7725674311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 4029 | FL | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | L9299 | 01 | FL | BLUE CROSS LAB | OTHER |