Basic Information
| Provider Information | |||||||||
| NPI: | 1609093632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YOUNG | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | ST JOHNS HOSPITAL | ||||||||
| Address2: | 800 EAST CARPENTER ST. | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627690001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175446464 | ||||||||
| FaxNumber: | 3097407479 | ||||||||
| Practice Location | |||||||||
| Address1: | ST JOHNS HOSPITAL | ||||||||
| Address2: | 800 EAST CARPENTER ST. | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627690001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175446464 | ||||||||
| FaxNumber: | 3097407479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 12/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 01073153A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.