Basic Information
| Provider Information | |||||||||
| NPI: | 1134345705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAYTON GASTROENTEROLOGY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 EXETER RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381383237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017374665 | ||||||||
| FaxNumber: | 9013281355 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 SYLVANIA DR | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454403237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373205050 | ||||||||
| FaxNumber: | 9373205060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROUSE | ||||||||
| AuthorizedOfficialFirstName: | BOBBY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9016821233 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3059523 | 05 | OH | MEDICAID |