Provider Demographics
NPI:1336172626
Name:SOUTHWEST VOLUSIA MEDICAL ASSOC.
Entity Type:Organization
Organization Name:SOUTHWEST VOLUSIA MEDICAL ASSOC.
Other - Org Name:FLORIDA HOSPITAL FISH MEMORIAL
Other - Org Type:Other Name
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WEIGAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-789-5550
Mailing Address - Street 1:1565 SAXON BLVD.
Mailing Address - Street 2:STE 202
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725
Mailing Address - Country:US
Mailing Address - Phone:386-789-5550
Mailing Address - Fax:386-532-7152
Practice Address - Street 1:1565 SAXON BLVD.
Practice Address - Street 2:STE 202
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725
Practice Address - Country:US
Practice Address - Phone:386-789-5550
Practice Address - Fax:386-532-7152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13473207Q00000X
207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL035188100Medicaid
D57592Medicare UPIN
FL035188100Medicaid