Basic Information
| Provider Information | |||||||||
| NPI: | 1407873292 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGERY CENTER OF VOLUSIA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SURGERY CENTER OF VOLUSIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3635 S CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321292300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867608151 | ||||||||
| FaxNumber: | 3867608185 | ||||||||
| Practice Location | |||||||||
| Address1: | 3635 S CLYDE MORRIS BLVD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321292300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867608151 | ||||||||
| FaxNumber: | 3867608185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 04/03/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLENDENIN | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1175 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 075540100 | 05 | FL | MEDICAID | P00073662 | 01 | FL | RAILROAD MEDICARE | OTHER |