Provider Demographics
NPI:1487108932
Name:DAYTON CHILDRENS HOSPITAL
Entity type:Organization
Organization Name:DAYTON CHILDRENS HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-641-5080
Mailing Address - Street 1:3333 W TECH RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-0955
Mailing Address - Country:US
Mailing Address - Phone:937-641-5080
Mailing Address - Fax:937-641-4848
Practice Address - Street 1:3333 W TECH RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-0955
Practice Address - Country:US
Practice Address - Phone:937-641-5080
Practice Address - Fax:937-641-4848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
OHCLPH.020612250-3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0180849Medicaid
OH3684481OtherNABP
BC2244034OtherDEA