Provider Demographics
NPI:1063641272
Name:DAYTON PAIN CENTER LLC
Entity Type:Organization
Organization Name:DAYTON PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:INDIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-222-2233
Mailing Address - Street 1:1 ELIZABETH PL
Mailing Address - Street 2:STE D
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45408-1445
Mailing Address - Country:US
Mailing Address - Phone:937-222-2233
Mailing Address - Fax:
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-222-2233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAYTON PAIN CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35035932R207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDA9338711Medicare PIN