Basic Information
| Provider Information | |||||||||
| NPI: | 1225192610 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAYTON CHILDREN'S SPECIALTY PHYSICIANS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS PLZ | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454041873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376413555 | ||||||||
| FaxNumber: | 9376414528 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CHILDRENS PLZ | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454041815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376414000 | ||||||||
| FaxNumber: | 9376414500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | BERGMAN | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
| AuthorizedOfficialTelephone: | 9376413338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CFO | ||||||||
| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Pediatrics | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 1223X0400X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 152WP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Pediatrics | 207PP0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207ZP0213X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0888633 | 05 | OH | MEDICAID | H557370 | 01 | MEDICARE | OTHER |