Provider Demographics
NPI:1124021324
Name:DAYTON CHILDREN'S ORTHOPAEDIC CENTER FOR SPINAL & PEDIATRIC CARE, LLC
Entity Type:Organization
Organization Name:DAYTON CHILDREN'S ORTHOPAEDIC CENTER FOR SPINAL & PEDIATRIC CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-641-3610
Mailing Address - Street 1:1 CHILDRENS PLZ
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-1898
Mailing Address - Country:US
Mailing Address - Phone:937-641-3010
Mailing Address - Fax:937-641-5003
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404
Practice Address - Country:US
Practice Address - Phone:937-641-3010
Practice Address - Fax:937-641-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH050826174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0060237Medicaid
KY65901415OtherKENTUCKY PASSPORT
KY65901415Medicaid
IN200251960AMedicaid
OH2125835800OtherBUREAU OF WORKERS COMP
OH2155448Medicaid
FL914700400Medicaid
OHCG2790OtherPARAMOUNT
OHCG2790OtherRAILROAD MEDICARE
OH2252233OtherAETNA
IN200251960AMedicaid
OH0060237Medicaid