1518948587 NPI number — DR. RICHARD W YOUNG DR

Table of content: DR. RICHARD W YOUNG DR (NPI 1518948587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518948587 NPI number — DR. RICHARD W YOUNG DR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
RICHARD
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DR
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:
1518948587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
MANAGED CARE DEPT
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
823 82ND PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29572-4607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-449-1010
Provider Business Practice Location Address Fax Number:
843-497-6171
Provider Enumeration Date:
11/08/2005

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: 208800000X , with the licence number:  MD16508 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 340011956 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: P00360569 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 165083 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 773672 . This is a "WELLCARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 890562Q , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP1418 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP4522 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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