Provider Demographics
NPI:1821160243
Name:ALLIANCE PHYSICIAN INC
Entity Type:Organization
Organization Name:ALLIANCE PHYSICIAN INC
Other - Org Name:KETTERING SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-558-3223
Mailing Address - Street 1:1 PRESTIGE PL
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3794
Mailing Address - Country:US
Mailing Address - Phone:937-762-1305
Mailing Address - Fax:937-522-7513
Practice Address - Street 1:4403 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2405
Practice Address - Country:US
Practice Address - Phone:937-395-3920
Practice Address - Fax:937-395-3940
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLIANCE PHYSICIANS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-14
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2864833Medicaid
OH2864833Medicaid