Basic Information
| Provider Information | |||||||||
| NPI: | 1154308476 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | USD DAYTON, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | DAYTON MEDICAL IMAGING CENTERVILLE SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 292921 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336872921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136752498 | ||||||||
| FaxNumber: | 8139710818 | ||||||||
| Practice Location | |||||||||
| Address1: | 7901 SCHATZ POINTE DR | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454593856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374390390 | ||||||||
| FaxNumber: | 9374397370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 02/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8136752600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | 1052IC | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0787091 | 05 | OH | MEDICAID |