Healthcare Provider Details

I. General information

NPI: 1659371433
Provider Name (Legal Business Name): COMMUNITY PHYSICIANS OF YELLOW SPRINGS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 XENIA AVE
YELLOW SPRINGS OH
45387-1121
US

IV. Provider business mailing address

1425 XENIA AVE
YELLOW SPRINGS OH
45387-1121
US

V. Phone/Fax

Practice location:
  • Phone: 937-376-3596
  • Fax: 937-767-1302
Mailing address:
  • Phone: 937-376-3596
  • Fax: 937-767-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35036419
License Number StateOH

VIII. Authorized Official

Name: PAUL VANAUSDAL
Title or Position: PRESIDENT
Credential: MD
Phone: 937-767-7291