1720037005 NPI number — DR. BOBBY YOUNG JOE M.D.

Table of content: DR. BOBBY YOUNG JOE M.D. (NPI 1720037005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720037005 NPI number — DR. BOBBY YOUNG JOE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOE
Provider First Name:
BOBBY
Provider Middle Name:
YOUNG
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOE
Provider Other First Name:
BOBBY
Provider Other Middle Name:
YOUNG
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1720037005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7630 PROUD LAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38119-9140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-754-2988
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13615 OLD HIGHWAY 61 NORTH
Provider Second Line Business Practice Location Address:
HARRAH'S TAKE CARE HEALTH AND WELLNESS CLINIC
Provider Business Practice Location Address City Name:
ROBINSONVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-357-3264
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  13992 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X , with the licence number: 9626 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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