=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659371433
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY PHYSICIANS OF YELLOW SPRINGS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 XENIA AVE
-----------------------------------------------------
City | YELLOW SPRINGS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45387-1121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-376-3596
-----------------------------------------------------
Fax | 937-767-1302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1425 XENIA AVE
-----------------------------------------------------
City | YELLOW SPRINGS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45387-1121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-376-3596
-----------------------------------------------------
Fax | 937-767-1302
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PAUL VANAUSDAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 937-767-7291
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35036419
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------