Basic Information
Provider Information | |||||||||
NPI: | 1568855104 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLIANCE PHYSICIANS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KETTERING HEALTH NETWORK GENETIC SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 PRESTIGE PL | ||||||||
Address2: | SUITE 550 | ||||||||
City: | MIAMISBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 453423794 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9377522305 | ||||||||
FaxNumber: | 9375227513 | ||||||||
Practice Location | |||||||||
Address1: | 3535 SOUTHERN BLVD | ||||||||
Address2: |   | ||||||||
City: | KETTERING | ||||||||
State: | OH | ||||||||
PostalCode: | 454291221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9373958646 | ||||||||
FaxNumber: | 9375228100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2015 | ||||||||
LastUpdateDate: | 03/24/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KO | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | Y | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 9375583208 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X |   | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207V00000X |   | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 170300000X |   | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Genetic Counselor, MS |   |
No ID Information.