Basic Information
| Provider Information | |||||||||
| NPI: | 1881664423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 PLAZA DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | ROSTRAVER TWP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150124019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243795802 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 PLAZA DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | ROSTRAVER TWP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150124019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243795802 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | SC003877L | PA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001582320 | 05 | PA | MEDICAID |