Basic Information
| Provider Information | |||||||||
| NPI: | 1790757854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 E WESTERN RESERVE RD | ||||||||
| Address2: | |||||||||
| City: | POLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445143358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307263204 | ||||||||
| FaxNumber: | 3307299316 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 E WESTERN RESERVE RD | ||||||||
| Address2: | |||||||||
| City: | POLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445143358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307263204 | ||||||||
| FaxNumber: | 3307299316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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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 | 207RC0000X | 35046446 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0631605 | 05 | OH | MEDICAID |