Basic Information
| Provider Information | |||||||||
| NPI: | 1740232552 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTH SPECIALISTS OF DAYTON INC | ||||||||
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| OtherOrganizationName: | W ROBERTS WOOD MD COMPANY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WYOMING ST | ||||||||
| Address2: | STE 4140 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372084110 | ||||||||
| FaxNumber: | 9372086260 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WYOMING ST | ||||||||
| Address2: | STE 4140 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372084110 | ||||||||
| FaxNumber: | 9372086260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 05/05/2010 | ||||||||
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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 | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2211930 | 05 | OH | MEDICAID |