Healthcare Provider Details

I. General information

NPI: 1417076803
Provider Name (Legal Business Name): DAYTON PAIN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 6TH AVE
SIDNEY OH
45365-1040
US

IV. Provider business mailing address

331 6TH AVE
SIDNEY OH
45365-1040
US

V. Phone/Fax

Practice location:
  • Phone: 937-497-9200
  • Fax:
Mailing address:
  • Phone: 937-497-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number35035932R
License Number StateOH

VIII. Authorized Official

Name: INDIRA B REDDY
Title or Position: OFFICE MANAGER
Credential: MD
Phone: 937-222-2233