Basic Information
| Provider Information | |||||||||
| NPI: | 1437135217 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | THEODORE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4297 | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803064297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035181931 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1015 BOWLES AVE | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364962000 | ||||||||
| FaxNumber: | 3149961681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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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 | 207P00000X | F3008 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 23542 | CO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | C50185 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2008028220 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00691434 | 01 | MO | RR MEDICARE INDIVIDUAL PTAN NUMBER | OTHER | 01235423 | 05 | CO | MEDICAID |