Provider Demographics
NPI:1073585741
Name:'YOUNG C FAN MD'
Entity Type:Organization
Organization Name:'YOUNG C FAN MD'
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YOUNG
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-827-4602
Mailing Address - Street 1:119 E MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-2161
Mailing Address - Country:US
Mailing Address - Phone:814-827-4602
Mailing Address - Fax:814-827-6322
Practice Address - Street 1:119 E MECHANIC ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-2161
Practice Address - Country:US
Practice Address - Phone:814-827-4602
Practice Address - Fax:814-827-6322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033897L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006010740001Medicaid
PA032140OtherPENNSYLVANIA BLUE SHIELD
PAB33821Medicare UPIN
PAFA032140Medicare ID - Type Unspecified