Basic Information
| Provider Information | |||||||||
| NPI: | 1346424165 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST VOLUSIA HEALTHCARE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHWEST VOLUSIA PROFESSIONAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 864623 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328864623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866714519 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1055 SAXON BLVD | ||||||||
| Address2: | |||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327638468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3869175017 | ||||||||
| FaxNumber: | 3869175019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2007 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GLASS | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3869175017 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHWEST VOLUSIA HEALTHCARE CORPORATION | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RP1001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 2084N0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 21677 | 01 | FL | BCBS FL | OTHER |