Basic Information
Provider Information | |||||||||
NPI: | 1194702415 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | USD DAYTON, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DAYTON MEDICAL IMAGING ENGLEWOOD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 292921 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336872921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136752498 | ||||||||
FaxNumber: | 8139710818 | ||||||||
Practice Location | |||||||||
Address1: | 1001 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ENGLEWOOD | ||||||||
State: | OH | ||||||||
PostalCode: | 453222818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9378369729 | ||||||||
FaxNumber: | 9378365721 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2005 | ||||||||
LastUpdateDate: | 02/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WRIGHT | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 8136752600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | 1053IC | OH | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
ID | Type | State | Issuer | Description | 0787091 | 05 | OH |   | MEDICAID |