Healthcare Provider Details

I. General information

NPI: 1467094425
Provider Name (Legal Business Name): OBSERVATION MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 SIMMONS LOOP
RIVERVIEW FL
33578-9498
US

IV. Provider business mailing address

PO BOX 10855
DAYTONA BEACH FL
32120-0855
US

V. Phone/Fax

Practice location:
  • Phone: 813-302-8000
  • Fax:
Mailing address:
  • Phone: 386-274-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DION RICHARD SAMERSON
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 813-874-5707