Provider Demographics
NPI:1366030538
Name:ALLIANCE MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:ALLIANCE MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-210-6504
Mailing Address - Street 1:6131 E HIGHWAY 191
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5348
Mailing Address - Country:US
Mailing Address - Phone:432-366-2911
Mailing Address - Fax:
Practice Address - Street 1:6131 E HIGHWAY 191
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5348
Practice Address - Country:US
Practice Address - Phone:432-366-2911
Practice Address - Fax:432-366-0790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160257OtherHEALTH AND HUMAN SERVICES
TX160260OtherHEALTH AND HUMAN SERVICES
TX160267OtherHEALTH AND HUMAN SERVICES