1295017689 NPI number — ALLIANCE PHYSICIAN INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295017689 NPI number — ALLIANCE PHYSICIAN INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLIANCE PHYSICIAN INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SYCAMORE PAIN MANAGEMENT CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295017689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2110 LEITER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMISBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45342-3660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-384-4838
Provider Business Mailing Address Fax Number:
937-384-4845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 MIAMISBURG CENTERVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 435
Provider Business Practice Location Address City Name:
MIAMISBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45342-3758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-384-4511
Provider Business Practice Location Address Fax Number:
937-384-4501
Provider Enumeration Date:
09/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HAIBACH
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DIRECTOR BUSINESS DEVELOPMENT
Authorized Official Telephone Number:
937-558-3222

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2712872 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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