Basic Information
| Provider Information | |||||||||
| NPI: | 1083986442 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLIANCE PHYSICIANS INC | ||||||||
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| OtherOrganizationName: | LEBANON HEMATOLOGY ONCOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373844838 | ||||||||
| FaxNumber: | 9373844845 | ||||||||
| Practice Location | |||||||||
| Address1: | 670 N BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450362590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132281552 | ||||||||
| FaxNumber: | 5132281558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2012 | ||||||||
| LastUpdateDate: | 10/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | KO | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9375583208 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLIANCE PHYSICIANS INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 35048340 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0060402 | 05 | OH | MEDICAID | 2712872 | 05 | OH | MEDICAID |