1902095078 NPI number — SOUTHWEST VOLUSIA HEALTHCARE CORPORATION

Table of content: (NPI 1902095078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902095078 NPI number — SOUTHWEST VOLUSIA HEALTHCARE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST VOLUSIA HEALTHCARE CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHWEST VOLUSIA MEDICAL ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902095078
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
770 W GRANADA BLVD STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-5179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-231-4252
Provider Business Mailing Address Fax Number:
386-676-2560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1055 SAXON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32763-8468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-917-5000
Provider Business Practice Location Address Fax Number:
386-917-5848
Provider Enumeration Date:
10/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GLASS
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
386-917-5017

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21677 . This is a "BCBS FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 116972300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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