Basic Information
| Provider Information | |||||||||
| NPI: | 1902844947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAYTON PHYSICIANS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAYTON PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6680 POE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372808366 | ||||||||
| FaxNumber: | 9372808373 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 N MAIN ST STE G-36 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372931622 | ||||||||
| FaxNumber: | 9372456308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | SERGENT | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9372808366 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 35055113 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 2085R0001X | 35070882R | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 208800000X | 35036788 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207RX0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | 35077949 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2609172 | 05 | OH | MEDICAID |