Healthcare Provider Details

I. General information

NPI: 1104108406
Provider Name (Legal Business Name): ALLIANCE PHYSICIAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL SUITE 10A-1
DAYTON OH
45417-3445
US

IV. Provider business mailing address

2110 LEITER RD
MIAMISBURG OH
45342-3660
US

V. Phone/Fax

Practice location:
  • Phone: 937-228-4126
  • Fax: 937-228-0247
Mailing address:
  • Phone: 937-384-4838
  • Fax: 937-384-4845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL D HAIBACH
Title or Position: DIRECTOR BUSINESS DEVELOPMENT
Credential:
Phone: 937-558-3222