Basic Information
| Provider Information | |||||||||
| NPI: | 1821160243 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALLIANCE PHYSICIAN INC | ||||||||
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| OtherOrganizationName: | KETTERING SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621305 | ||||||||
| FaxNumber: | 9375227513 | ||||||||
| Practice Location | |||||||||
| Address1: | 4403 FAR HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454292405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373953920 | ||||||||
| FaxNumber: | 9373953940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | KO | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9375583223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALLIANCE PHYSICIANS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2864833 | 05 | OH | MEDICAID |