1023311990 NPI number — INFECTIOUS DISEASE PHYSICIANS OF DAYTON LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023311990 NPI number — INFECTIOUS DISEASE PHYSICIANS OF DAYTON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFECTIOUS DISEASE PHYSICIANS OF DAYTON LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023311990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 652
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGBORO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45066-0652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-885-0464
Provider Business Mailing Address Fax Number:
937-885-0464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9000 N MAIN ST
Provider Second Line Business Practice Location Address:
INFUSION SERVICES
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45415-1180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-279-5803
Provider Business Practice Location Address Fax Number:
937-279-5873
Provider Enumeration Date:
12/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SORG
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
937-885-0464

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  35-05-3064 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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