=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548584600
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST VOLUSIA FAMILY AND SPORTS MEDICINE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2010
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1590 S STATE ROAD 15A STE 100
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-7817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-774-0016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1590 S STATE ROAD 15A STE 100
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-7817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-774-0016
-----------------------------------------------------
Fax | 386-774-0606
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PROVIDER
-----------------------------------------------------
Name | JOHN HILL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 386-774-0016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME93242
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------