Basic Information
| Provider Information | |||||||||
| NPI: | 1902448715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VOLUSIA MEDICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 N. STONE STREET | ||||||||
| Address2: | |||||||||
| City: | DELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864241584 | ||||||||
| FaxNumber: | 3864104800 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 N. STONE STREET | ||||||||
| Address2: | |||||||||
| City: | DELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864241584 | ||||||||
| FaxNumber: | 3864104800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2019 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | STOREY | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MA/OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3864241584 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VOLUSIA MEDICAL CENTER LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009910800 | 05 | FL | MEDICAID |