Healthcare Provider Details

I. General information

NPI: 1316923915
Provider Name (Legal Business Name): DAYTON INTERVENTIONAL RADIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 GOVERNORS PLACE BLVD
KETTERING OH
45409-1323
US

IV. Provider business mailing address

PO BOX 412865
BOSTON MA
02241-2865
US

V. Phone/Fax

Practice location:
  • Phone: 937-765-3113
  • Fax:
Mailing address:
  • Phone: 610-644-8900
  • Fax: 484-924-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.003246
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGG MILLER
Title or Position: SR. VICE PRESIDENT
Credential: MD
Phone: 610-644-8900