Provider Demographics
NPI:1346424165
Name:SOUTHWEST VOLUSIA HEALTHCARE CORPORATION
Entity Type:Organization
Organization Name:SOUTHWEST VOLUSIA HEALTHCARE CORPORATION
Other - Org Name:SOUTHWEST VOLUSIA PROFESSIONAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-917-5017
Mailing Address - Street 1:PO BOX 864623
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-4623
Mailing Address - Country:US
Mailing Address - Phone:386-671-4519
Mailing Address - Fax:
Practice Address - Street 1:1055 SAXON BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8468
Practice Address - Country:US
Practice Address - Phone:386-917-5017
Practice Address - Fax:386-917-5019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST VOLUSIA HEALTHCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-28
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21677OtherBCBS FL
FL100072Medicare Oscar/Certification
FL40097Medicare PIN