Provider Demographics
NPI:1902095078
Name:SOUTHWEST VOLUSIA HEALTHCARE CORPORATION
Entity type:Organization
Organization Name:SOUTHWEST VOLUSIA HEALTHCARE CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
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 1:770 W GRANADA BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5179
Mailing Address - Country:US
Mailing Address - Phone:386-231-4252
Mailing Address - Fax:386-676-2560
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:386-917-5000
Practice Address - Fax:386-917-5848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST VOLUSIA HEALTHCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-15
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL21677OtherBCBS FL
FL40097Medicare PIN
FL21677OtherBCBS FL