Provider Demographics
NPI:1245222108
Name:BUTLER-MOO YOUNG, NICHOLE M (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:M
Last Name:BUTLER-MOO YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICHOLE
Other - Middle Name:M
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-8801
Mailing Address - Country:US
Mailing Address - Phone:630-469-2000
Mailing Address - Fax:
Practice Address - Street 1:12150 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1435
Practice Address - Country:US
Practice Address - Phone:708-388-0785
Practice Address - Fax:708-388-1579
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099421207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099421Medicaid
ILH83198Medicare UPIN
ILF400119079Medicare PIN