Basic Information
| Provider Information | |||||||||
| NPI: | 1871557355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNGBERG | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 326 | ||||||||
| Address2: | |||||||||
| City: | VINITA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743010326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182567551 | ||||||||
| FaxNumber: | 9182563703 | ||||||||
| Practice Location | |||||||||
| Address1: | 735 N FOREMAN ST | ||||||||
| Address2: | |||||||||
| City: | VINITA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743011422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182567551 | ||||||||
| FaxNumber: | 9182563703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 06/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2410 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | R5H41 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200355260A | 05 | KS | MEDICAID | 431704371 | 01 | TAX ID FOR FREEMAN | OTHER | 243419306 | 05 | MO | MEDICAID |