Provider Demographics
NPI:1467094425
Name:OBSERVATION MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:OBSERVATION MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DION
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:SAMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-874-5707
Mailing Address - Street 1:PO BOX 10855
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-0855
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:
Practice Address - Street 1:6901 SIMMONS LOOP
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-9498
Practice Address - Country:US
Practice Address - Phone:813-302-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty