1083694665 NPI number — DR. THOMAS YOUNG M.D.

Table of content: DR. THOMAS YOUNG M.D. (NPI 1083694665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083694665 NPI number — DR. THOMAS YOUNG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
THOMAS
Provider Middle Name:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083694665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 ROSS CLARK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36301-3022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-712-1929
Provider Business Mailing Address Fax Number:
334-712-2799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 ROSS CLARK CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301-3022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-712-1929
Provider Business Practice Location Address Fax Number:
334-712-2799
Provider Enumeration Date:
01/19/2006

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: 207RC0000X , with the licence number:  16584 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 370489100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 370489101 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051088715 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 370489102 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000088715 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051540112 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 00505689B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61700 . This is a "BLUE CROSS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 631087996 . This is a "TAX ID#" identifier . This identifiers is of the category "OTHER".
  • Identifier: 009942275 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051055300 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051095000 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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