Basic Information
| Provider Information | |||||||||
| NPI: | 1184647992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | GABRUCE | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 PROFESSIONAL LN | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363302085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343473404 | ||||||||
| FaxNumber: | 3343930613 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PROFESSIONAL LN | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363302085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343473404 | ||||||||
| FaxNumber: | 3343930613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 08/07/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20231 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009913147 | 05 | AL | MEDICAID | 515-45639 | 01 | AL | BLUE CROSS BLUE SHIELD OF ALABAMA | OTHER |