Provider Demographics
NPI:1184610099
Name:SOUTH VOLUSIA MEDICAL ASSOC
Entity type:Organization
Organization Name:SOUTH VOLUSIA MEDICAL ASSOC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:LEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-788-1881
Mailing Address - Street 1:317 S DIXIE FWY
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7158
Mailing Address - Country:US
Mailing Address - Phone:386-426-8600
Mailing Address - Fax:386-426-6090
Practice Address - Street 1:317 S DIXIE FWY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7158
Practice Address - Country:US
Practice Address - Phone:386-426-8600
Practice Address - Fax:386-426-6090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40908Medicare ID - Type Unspecified