1629147103 NPI number — GAVIN S YOUNG MD

Table of content: GAVIN S YOUNG MD (NPI 1629147103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629147103 NPI number — GAVIN S YOUNG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
GAVIN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1629147103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2003 KOOTENAI HEALTH WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814-6051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-625-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 LINCOLN WAY
Provider Second Line Business Practice Location Address:
SUITE 415
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814-2527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-625-4595
Provider Business Practice Location Address Fax Number:
208-625-4596
Provider Enumeration Date:
11/07/2006

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: 207RG0100X , with the licence number:  M7978 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 805774200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com