Basic Information
Provider Information | |||||||||
NPI: | 1255308672 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OH | ||||||||
FirstName: | YOUNG-HO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 94 SOUTH ST | ||||||||
Address2: |   | ||||||||
City: | SOUTHBRIDGE | ||||||||
State: | MA | ||||||||
PostalCode: | 015504000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087642772 | ||||||||
FaxNumber: | 5087642833 | ||||||||
Practice Location | |||||||||
Address1: | 94 SOUTH ST | ||||||||
Address2: |   | ||||||||
City: | SOUTHBRIDGE | ||||||||
State: | MA | ||||||||
PostalCode: | 015504000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087642772 | ||||||||
FaxNumber: | 5087642833 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2006 | ||||||||
LastUpdateDate: | 12/21/2011 | ||||||||
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 | 207X00000X | 205013 | MA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 2615923 | 01 | MA | AETNA HEALTH CARE | OTHER | 4779737001 | 01 | MA | CIGNA | OTHER | 0024375 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 09-02806 | 01 | MA | UNITED HEALTH | OTHER | 172450 | 01 | MA | HARVARD PILGRIM HEALTH | OTHER | 0138126 | 05 | MA |   | MEDICAID | J23603 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 62252 | 01 | MA | FALLON SELECT | OTHER | 200042843 | 01 | MA | RAIL ROAD MEDICARE | OTHER | 205013 | 01 | MA | TUFTS | OTHER |