Provider Demographics
NPI:1194288514
Name:YELLOW SPRINGS PRIMARY CARE, INC
Entity type:Organization
Organization Name:YELLOW SPRINGS PRIMARY CARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:GRONBECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-767-1088
Mailing Address - Street 1:888 DAYTON ST UNIT 106
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1778
Mailing Address - Country:US
Mailing Address - Phone:937-767-1088
Mailing Address - Fax:937-767-1022
Practice Address - Street 1:888 DAYTON ST UNIT 106
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1778
Practice Address - Country:US
Practice Address - Phone:937-767-1088
Practice Address - Fax:937-767-1022
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YELLOW SPRINGS PRIMARY CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-11
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH363873OtherCCN