Healthcare Provider Details

I. General information

NPI: 1821160243
Provider Name (Legal Business Name): ALLIANCE PHYSICIAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 FAR HILLS AVE
KETTERING OH
45429-2405
US

IV. Provider business mailing address

1 PRESTIGE PL SUITE 550
MIAMISBURG OH
45342-3794
US

V. Phone/Fax

Practice location:
  • Phone: 937-395-3920
  • Fax: 937-395-3940
Mailing address:
  • Phone: 937-762-1305
  • Fax: 937-522-7513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY Y KO
Title or Position: CFO
Credential:
Phone: 937-558-3223