Healthcare Provider Details

I. General information

NPI: 1154002772
Provider Name (Legal Business Name): MVC FL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 NE 138TH LN STE 2000D
LADY LAKE FL
32159-8957
US

IV. Provider business mailing address

7125 ORCHARD LAKE RD STE 100
WEST BLOOMFIELD MI
48322-3616
US

V. Phone/Fax

Practice location:
  • Phone: 866-607-2308
  • Fax:
Mailing address:
  • Phone: 866-607-2308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MATT KIRK
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 708-710-9931