Basic Information
| Provider Information | |||||||||
| NPI: | 1952399511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | ROGER | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 W WHITTAKER ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628811917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185483740 | ||||||||
| FaxNumber: | 6185483705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 W WHITTAKER ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628811917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185483740 | ||||||||
| FaxNumber: | 6185483705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 10/16/2013 | ||||||||
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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 | 363L00000X | 041255812 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 110230526 | 01 | IL | RAILROAD MEDICARE | OTHER | 207988 | 01 | IL | GRP MEDICARE NUMBER | OTHER | CJ2166 | 01 | IL | RR MEDICARE GROUP NUMBER | OTHER | 500025714 | 01 | IL | RAILROAD MEDICARE NUMBER | OTHER | 208959 | 01 | IL | GRP MEDICARE NUMBER | OTHER |