1538252077 NPI number — DR. CHARLES C YOUNG M.D.

Table of content: DR. CHARLES C YOUNG M.D. (NPI 1538252077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538252077 NPI number — DR. CHARLES C YOUNG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
CHARLES
Provider Middle Name:
C
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:
1538252077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1812 DALEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAWLINS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82301-5912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-324-6711
Provider Business Mailing Address Fax Number:
307-324-3594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1812 DALEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAWLINS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82301-5912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-324-6711
Provider Business Practice Location Address Fax Number:
307-324-3594
Provider Enumeration Date:
10/02/2006

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: 207Q00000X , with the licence number:  5353A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 344550 . This is a "COMBINED INSURANCE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 307083 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 109204900 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5353A . This is a "LICENSE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 850335622 . This is a "TAX ID" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 080086864 . This is a "PALMETTO" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 53D0909290 . This is a "CLIA" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 490301955 . This is a "LAB CORP" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 563365 . This is a "WY WORKERS COMPENSATION" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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