Basic Information
| Provider Information | |||||||||
| NPI: | 1407377500 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAYTON CHILDREN'S HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DAYTON CHILDREN'S HOSPITAL REFERENCE LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS PLZ | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454041873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376413000 | ||||||||
| FaxNumber: | 9376415403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CHILDRENS PLZ | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454041873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376413000 | ||||||||
| FaxNumber: | 9376413326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2017 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERGMAN | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | C.F.O. | ||||||||
| AuthorizedOfficialTelephone: | 9376413338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | OH | N | Hospitals | General Acute Care Hospital | Children | 291U00000X | OH | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 363306 | 01 | MEDICARE | OTHER | 0465509 | 05 | OH | MEDICAID |