MEDICARE: DAYTON CHILDREN'S ORTHOPAEDIC CENTER FOR SPINAL & PEDIATRIC CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	050826	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
9	CG2790	OTHER	OH	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	65901415	OTHER	KY	KENTUCKY PASSPORT
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	2125835800	OTHER	OH	BUREAU OF WORKERS COMP
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	CG2790	OTHER	OH	PARAMOUNT
10	2252233	OTHER	OH	AETNA

General Provider Information

NPI Number	:	1124021324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAYTON CHILDREN'S ORTHOPAEDIC CENTER FOR SPINAL & PEDIATRIC CARE, LLC

Provider Business Mailing Address
First Line	:	1 CHILDRENS PLZ
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45404-1898
Country	:	US
Telephone Number	:	937-641-3010
Fax Number	:	937-641-5003

Provider Business Practice Location Address
First Line	:	1 CHILDRENS PLZ
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45404
Country	:	US
Telephone Number	:	937-641-3010
Fax Number	:	937-641-5003

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. LISA COFFEY
Credential	:
Telephone Number	:	937-641-3610

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	06/19/2018

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