Basic Information
| Provider Information | |||||||||
| NPI: | 1336172626 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST VOLUSIA MEDICAL ASSOC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORIDA HOSPITAL FISH MEMORIAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1565 SAXON BLVD. | ||||||||
| Address2: | STE 202 | ||||||||
| City: | DELTONA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867895550 | ||||||||
| FaxNumber: | 3865327152 | ||||||||
| Practice Location | |||||||||
| Address1: | 1565 SAXON BLVD. | ||||||||
| Address2: | STE 202 | ||||||||
| City: | DELTONA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867895550 | ||||||||
| FaxNumber: | 3865327152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 06/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | WEIGAND | ||||||||
| AuthorizedOfficialFirstName: | FREDERICK | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | DR. | ||||||||
| AuthorizedOfficialTelephone: | 3867895550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 13473 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0505X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 035188100 | 05 | FL | MEDICAID |