Basic Information
| Provider Information | |||||||||
| NPI: | 1811121619 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLIANCE PHYSICIANS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIAMISBURG FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10050 INNOVATION DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453424931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375583208 | ||||||||
| FaxNumber: | 9375583247 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 BYERS RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378662494 | ||||||||
| FaxNumber: | 9378668494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KO | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9375583223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLIANCE PHYSICIANS INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3011118 | 05 | OH | MEDICAID | 2712872 | 05 | OH | MEDICAID |