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  5. OB & GYN SPECIALISTS, P.A.

OB & GYN SPECIALISTS, P.A.

Company Details

Entity Name: OB & GYN SPECIALISTS, P.A.
Jurisdiction: FLORIDA
Filing Type: Florida Profit Corporation
Status: Inactive
Date Filed: 01 Jan 1980 (45 years ago)
Date of dissolution: 28 Sep 2012 (12 years ago)
Last Event: ADMIN DISSOLUTION FOR ANNUAL REPORT
Event Date Filed: 28 Sep 2012 (12 years ago)
Document Number: 649549
FEI/EIN Number 59-1960318
Address: 1551 CLAY STREET, WINTER PARK, FL 32789
Mail Address: 1551 CLAY STREET, WINTER PARK, FL 32789
ZIP code: 32789
County: Orange
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1184760506 2007-01-30 2008-01-09 1551 CLAY ST, WINTER PARK, FL, 327895499, US 1551 CLAY ST, WINTER PARK, FL, 327895499, US

Contacts
Phone +1 407-644-5371
Fax 4076441417

Authorized person
Name MATTHEW R MERVIS
Role ADMINISTRATOR
Phone 4076445371

Taxonomy
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0030235
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0030722
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0043553
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0049918
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0063738
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0064647
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0062994
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0067143
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0071558
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0083622
State FL
Is Primary Yes
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME0086331
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME99195
State FL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
License Number ME100440
State FL
Is Primary No

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
401K/PROFIT SHARING PLAN AND TRUST FOR EMPLOYEES OF OB & GYN SPECIALISTS, P.A. 2011 591960318 2012-05-30 OB & GYN SPECIALISTS, P.A. 72
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1980-01-01
Business code 621111
Sponsor’s telephone number 4075995900
Plan sponsor’s address 1551 CLAY STREET, WINTER PARK, FL, 32789

Plan administrator’s name and address
Administrator’s EIN 591960318
Plan administrator’s name OB & GYN SPECIALISTS, P.A.
Plan administrator’s address 1551 CLAY STREET, WINTER PARK, FL, 32789
Administrator’s telephone number 4075995900

Signature of
Role Plan administrator
Date 2012-05-30
Name of individual signing MARK A. WILSTRUP, M.D.
Valid signature Filed with authorized/valid electronic signature
401K/PROFIT SHARING PLAN AND TRUST FOR EMPLOYEES OF OB & GYN SPECIALISTS, P.A. 2010 591960318 2011-06-09 OB & GYN SPECIALISTS, P.A. 73
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1980-01-01
Business code 621111
Sponsor’s telephone number 4075995900
Plan sponsor’s address 1551 CLAY STREET, WINTER PARK, FL, 32789

Plan administrator’s name and address
Administrator’s EIN 591960318
Plan administrator’s name OB & GYN SPECIALISTS, P.A.
Plan administrator’s address 1551 CLAY STREET, WINTER PARK, FL, 32789
Administrator’s telephone number 4075995900

Signature of
Role Plan administrator
Date 2011-06-09
Name of individual signing MATTHEW R. MERVIS, M.D.
Valid signature Filed with authorized/valid electronic signature
401K/PROFIT SHARING PLAN AND TRUST FOR EMPLOYEES OF OB & GYN SPECIALISTS, P.A. 2009 591960318 2010-10-11 OB & GYN SPECIALISTS, P.A. 74
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1980-01-01
Business code 621111
Sponsor’s telephone number 4075995900
Plan sponsor’s address 1551 CLAY STREET, WINTER PARK, FL, 32789

Plan administrator’s name and address
Administrator’s EIN 591960318
Plan administrator’s name OB & GYN SPECIALISTS, P.A.
Plan administrator’s address 1551 CLAY STREET, WINTER PARK, FL, 32789
Administrator’s telephone number 4075995900

Signature of
Role Plan administrator
Date 2010-10-11
Name of individual signing MATTHEW R. MERVIS, M.D.
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
DIEBEL, N. DONALD M.D. Agent 1551 CLAY STREET, WINTER PARK, FL 32789

President

Name Role Address
DIEBEL, N DONALD M.D. President 1551 CLAY STREET, WINTER PARK, FL 32789

Director

Name Role Address
DIEBEL, N DONALD M.D. Director 1551 CLAY STREET, WINTER PARK, FL 32789
WILSTRUP, MARK AM.D. Director 1551 CLAY STREET, WINTER PARK, FL 32789
LAZAR, ARNOLD JM.D. Director 1551 CLAY STREET, WINTER PARK, FL 32789
DURKEE, DENNISE CM.D. Director 1551 CLAY STREET, WINTER PARK, FL 32789
MERVIS, MATTHEW RM.D. Director 1551 CLAY STREET, WINTER PARK, FL 32789
CARDUCCI, THERESA JM.D. Director 1551 CLAY STREET, WINTER PARK, FL 32789

Secretary

Name Role Address
WILSTRUP, MARK AM.D. Secretary 1551 CLAY STREET, WINTER PARK, FL 32789

Treasurer

Name Role Address
LAZAR, ARNOLD JM.D. Treasurer 1551 CLAY STREET, WINTER PARK, FL 32789

Assistant Secretary

Name Role Address
DURKEE, DENNISE CM.D. Assistant Secretary 1551 CLAY STREET, WINTER PARK, FL 32789

Assistant Treasurer

Name Role Address
MERVIS, MATTHEW RM.D. Assistant Treasurer 1551 CLAY STREET, WINTER PARK, FL 32789

Vice President

Name Role Address
CARDUCCI, THERESA JM.D. Vice President 1551 CLAY STREET, WINTER PARK, FL 32789

Events

Event Type Filed Date Value Description
ADMIN DISSOLUTION FOR ANNUAL REPORT 2012-09-28 No data No data
CHANGE OF PRINCIPAL ADDRESS 2010-04-09 1551 CLAY STREET, WINTER PARK, FL 32789 No data
CANCEL ADM DISS/REV 2009-12-18 No data No data
REGISTERED AGENT NAME CHANGED 2009-12-18 DIEBEL, N. DONALD M.D. No data
ADMIN DISSOLUTION FOR ANNUAL REPORT 2009-09-25 No data No data
NAME CHANGE AMENDMENT 1987-10-05 OB & GYN SPECIALISTS, P.A. No data
NAME CHANGE AMENDMENT 1986-07-11 OB & GYN SPECIALISTS, DIEBEL, LAZAR, STROUP, EPLEY AND WILSTRUP, M.D., P.A. No data
NAME CHANGE AMENDMENT 1983-06-15 OB & GYN SPECIALISTS, DIEBEL, LAZAR AND STROUP, M.D., P.A. No data
CHANGE OF MAILING ADDRESS 1982-04-07 1551 CLAY STREET, WINTER PARK, FL 32789 No data
REGISTERED AGENT ADDRESS CHANGED 1982-04-07 1551 CLAY STREET, WINTER PARK, FL 32789 No data

Documents

Name Date
ANNUAL REPORT 2011-03-18
ANNUAL REPORT 2010-04-09
REINSTATEMENT 2009-12-18
ANNUAL REPORT 2008-05-02
ANNUAL REPORT 2007-04-30
ANNUAL REPORT 2006-05-09
ANNUAL REPORT 2005-05-02
ANNUAL REPORT 2004-07-15
ANNUAL REPORT 2003-02-10
ANNUAL REPORT 2002-03-12

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 05 Feb 2025

Sources: Florida Department of State

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