Basic Information
| Provider Information | |||||||||
| NPI: | 1548584600 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST VOLUSIA FAMILY AND SPORTS MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23764 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336233764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278280723 | ||||||||
| Practice Location | |||||||||
| Address1: | 742 N VOLUSIA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327634857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867740016 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2010 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | HILL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 3867740016 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME93242 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002241400 | 05 | FL | MEDICAID | 000TF | 01 | FL | BCBS | OTHER |