1952399511 NPI number — ROGER YOUNG NP

Table of content: ROGER YOUNG NP (NPI 1952399511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952399511 NPI number — ROGER YOUNG NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
ROGER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1952399511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 W WHITTAKER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62881-1917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-548-3740
Provider Business Mailing Address Fax Number:
618-548-3705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 W WHITTAKER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62881-1917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-548-3740
Provider Business Practice Location Address Fax Number:
618-548-3705
Provider Enumeration Date:
10/07/2005

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: 363L00000X , with the licence number:  041255812 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110230526 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 207988 . This is a "GRP MEDICARE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CJ2166 . This is a "RR MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 500025714 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 208959 . This is a "GRP MEDICARE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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