Basic Information
| Provider Information | |||||||||
| NPI: | 1437340825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH SPECIALISTS OF DAYTON INC | ||||||||
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| OtherOrganizationName: | MELISSA P ROELLE MD COMPANY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ELIZABETH PL | ||||||||
| Address2: | STE 10A | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454081445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372280248 | ||||||||
| FaxNumber: | 9372280247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ELIZABETH PL | ||||||||
| Address2: | STE 10A | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454081445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372280248 | ||||||||
| FaxNumber: | 9372280247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | PRUNIER | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9372088213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH SPECIALISTS OF DAYTON INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2764512 | 05 | OH | MEDICAID |