Provider Demographics
NPI:1033214994
Name:YOUNG, MICHEAL (MD)
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2101
Mailing Address - Country:US
Mailing Address - Phone:309-664-3000
Mailing Address - Fax:309-664-3026
Practice Address - Street 1:1701 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2101
Practice Address - Country:US
Practice Address - Phone:309-664-3038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097611208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2613OtherMEDICARE GROUP PTAN
ILIL2613017Medicare PIN
ILIL2613OtherMEDICARE GROUP PTAN
ILG80738Medicare UPIN