Basic Information
| Provider Information | |||||||||
| NPI: | 1356494595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 PEAKE RD | ||||||||
| Address2: | #700 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312108042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784769285 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6501 PEAKE RD | ||||||||
| Address2: | #700 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312108042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784769285 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 12/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036325 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000518207G | 05 | GA | MEDICAID | 52029199 | 01 | GA | BCBS OF GEORGIA | OTHER |