Provider Demographics
NPI:1275586455
Name:DAYTON SPINE AND REHABILITATION MEDICINE LTD
Entity Type:Organization
Organization Name:DAYTON SPINE AND REHABILITATION MEDICINE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:KINNAIRD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-435-3620
Mailing Address - Street 1:2591 MIAMISBURG CENTERVILLE RD
Mailing Address - Street 2:STE 300
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3706
Mailing Address - Country:US
Mailing Address - Phone:937-435-3620
Mailing Address - Fax:937-435-3660
Practice Address - Street 1:2591 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:STE 300
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-3706
Practice Address - Country:US
Practice Address - Phone:937-435-3620
Practice Address - Fax:937-435-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200901300AMedicaid
OH2057045Medicaid
OHCH8332Medicare PIN
OH2057045Medicaid