Basic Information
| Provider Information | |||||||||
| NPI: | 1700978558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST VOLUSIA HEALTHCARE CORPORATION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FLORIDA HOSPITAL FISH MEMORIAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 W GRANADA BLVD STE 203 | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321745179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862314252 | ||||||||
| FaxNumber: | 3866762560 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 SAXON BLVD | ||||||||
| Address2: | |||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327638468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3869175000 | ||||||||
| FaxNumber: | 3869175019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GLASS | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3869175017 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 4408 | FL | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 010182600 | 05 | FL | MEDICAID | 318 | 01 | FL | BLUE CROSS FLORIDA | OTHER |