Provider Demographics
NPI:1073612644
Name:MARIANNE YOUNG PHYSICIAN PC
Entity Type:Organization
Organization Name:MARIANNE YOUNG PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-249-2242
Mailing Address - Street 1:172 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3968
Mailing Address - Country:US
Mailing Address - Phone:516-248-3685
Mailing Address - Fax:
Practice Address - Street 1:175 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4532
Practice Address - Country:US
Practice Address - Phone:631-249-2242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208596207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02162196Medicaid
NYWEX151Medicare ID - Type Unspecified
NY02162196Medicaid