Basic Information
| Provider Information | |||||||||
| NPI: | 1912987256 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEART HOSPITAL OF DTO, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DAYTON HEART HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 SOUTH EDWIN C. MOSES BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454081462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372218000 | ||||||||
| FaxNumber: | 9372218801 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 S. EDWIN C. MOSES BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372218000 | ||||||||
| FaxNumber: | 9372218801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLEMENTS | ||||||||
| AuthorizedOfficialFirstName: | CATHI | ||||||||
| AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE TEAM LEADER | ||||||||
| AuthorizedOfficialTelephone: | 9372218070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 1431 | OH | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 2166016 | 05 | OH | MEDICAID |