Provider Demographics
NPI:1770864480
Name:ALLIANCE PHYSICIAN INC
Entity Type:Organization
Organization Name:ALLIANCE PHYSICIAN INC
Other - Org Name:HERITAGE FAMILY PRACTICE ROSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAIBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-558-3222
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3660
Mailing Address - Country:US
Mailing Address - Phone:937-384-4838
Mailing Address - Fax:937-384-4845
Practice Address - Street 1:3740 ROSSGATE CT
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-8687
Practice Address - Country:US
Practice Address - Phone:513-738-3900
Practice Address - Fax:513-738-7283
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLIANCE PHYSICIAN INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2712872Medicaid
OH9306898Medicare PIN