Basic Information
| Provider Information | |||||||||
| NPI: | 1831503853 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENE MEMORIAL HOSPITAL INC | ||||||||
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| OtherOrganizationName: | COMMUNITY PHYSICIANS OF YELLOW SPRINGS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379147601 | ||||||||
| FaxNumber: | 9375227685 | ||||||||
| Practice Location | |||||||||
| Address1: | 888 DAYTON ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | YELLOW SPRINGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453871777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377677291 | ||||||||
| FaxNumber: | 9377371302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2014 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOTELLING | ||||||||
| AuthorizedOfficialFirstName: | DANN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9377621644 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREENE MEMORIAL HOSPITAL INC | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0144766 | 05 | OH | MEDICAID |