Provider Demographics
NPI:1609045012
Name:PEDIATRIC ASSOCIATES OF DAYTON, INC.
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF DAYTON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-832-7337
Mailing Address - Street 1:9000 N MAIN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1180
Mailing Address - Country:US
Mailing Address - Phone:937-832-7337
Mailing Address - Fax:937-832-4817
Practice Address - Street 1:5450 FAR HILLS AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2386
Practice Address - Country:US
Practice Address - Phone:937-436-2866
Practice Address - Fax:937-436-1468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2637543Medicaid