Provider Demographics
NPI:1023335437
Name:WEST VOLUSIA SURGICAL, PA
Entity type:Organization
Organization Name:WEST VOLUSIA SURGICAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:OGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-443-1865
Mailing Address - Street 1:321 MONTGOMERY RD #160965
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-0965
Mailing Address - Country:US
Mailing Address - Phone:407-409-8111
Mailing Address - Fax:407-409-8115
Practice Address - Street 1:321 MONTGOMERY RD #160965
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32716-0965
Practice Address - Country:US
Practice Address - Phone:407-409-8111
Practice Address - Fax:407-409-8115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98314208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278168900Medicaid
FL278168900Medicaid