Provider Demographics
NPI:1063037877
Name:YOUNG, CARLY BETH (MD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:BETH
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22250 PROVIDENCE DR STE 703A
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22250 PROVIDENCE DR STE 703A
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6215
Practice Address - Country:US
Practice Address - Phone:248-849-5862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351046897208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery