Provider Demographics
NPI:1083663371
Name:YOUNG, RODNEY BERT III (MD)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:BERT
Last Name:YOUNG
Suffix:III
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 1:2801 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9172
Mailing Address - Country:US
Mailing Address - Phone:843-797-5252
Mailing Address - Fax:843-797-3683
Practice Address - Street 1:2801 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9172
Practice Address - Country:US
Practice Address - Phone:843-797-5252
Practice Address - Fax:843-797-3683
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11077208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC110775Medicaid
SC110775Medicaid