Basic Information
| Provider Information | |||||||||
| NPI: | 1861488892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 W WELLINGTON AVE | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606574325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732811011 | ||||||||
| FaxNumber: | 7732811029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 W WELLINGTON AVE | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606574325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732811011 | ||||||||
| FaxNumber: | 7732811029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 11/11/2013 | ||||||||
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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 | 208800000X | 036073765 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | P00661914 | 01 | RAILROAD MEDICARE | OTHER | 036101015 | 05 | IL | MEDICAID | 1635877 | 01 | BCBS | OTHER |