MEDICARE: DAYTON INTERVENTIONAL RADIOLOGY 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	213ES0103X	Foot & Ankle Surgery Podiatrist	36.003246	OH
2	2085R0204X	Vascular & Interventional Radiology Physician

General Provider Information

NPI Number	:	1316923915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAYTON INTERVENTIONAL RADIOLOGY LLC

Provider Business Mailing Address
First Line	:	PO BOX 412865
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-2865
Country	:	US
Telephone Number	:	610-644-8900
Fax Number	:	484-924-0053

Provider Business Practice Location Address
First Line	:	3075 GOVERNORS PLACE BLVD
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45409-1323
Country	:	US
Telephone Number	:	937-765-3113
Fax Number	:

Authorized Official
Title or Position	:	SR. VICE PRESIDENT
Name	:	GREGG MILLER
Credential	:	MD
Telephone Number	:	610-644-8900

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	10/13/2021

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