Basic Information
| Provider Information | |||||||||
| NPI: | 1154303907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | GARRET | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 12065 | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285612065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526335057 | ||||||||
| FaxNumber: | 2526330084 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 NEWMAN RD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285625238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526335057 | ||||||||
| FaxNumber: | 2526330084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 11/21/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 39719 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085B0100X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085D0003X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2085U0001X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085N0700X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0001X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0205X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Radiological Physics | 2085R0203X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 207U00000X | 39719 | NC | N | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1141C | 01 | NC | BCBS OF NC | OTHER | 153000500 | 01 | NC | DOL | OTHER | 760158 | 01 | NC | MAMSI | OTHER | 150918 | 01 | NC | VYTRA | OTHER | C5188 | 01 | NC | MEDCOST | OTHER | 891141C | 05 | NC | MEDICAID |