Basic Information
| Provider Information | |||||||||
| NPI: | 1962496844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YUNGER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9001 N MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378320990 | ||||||||
| FaxNumber: | 9378327323 | ||||||||
| Practice Location | |||||||||
| Address1: | 9001 N MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378320990 | ||||||||
| FaxNumber: | 9378327323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 02/10/2011 | ||||||||
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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 | 174400000X | OH 35-07-1174Y | OH | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2092891 | 05 | OH | MEDICAID |