Provider Demographics
NPI:1356494595
Name:YOUNG, EDWARD H (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:H
Last Name:YOUNG
Suffix:
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 1:6501 PEAKE RD
Mailing Address - Street 2:#700
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-8042
Mailing Address - Country:US
Mailing Address - Phone:478-476-9285
Mailing Address - Fax:
Practice Address - Street 1:6501 PEAKE RD
Practice Address - Street 2:#700
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-8042
Practice Address - Country:US
Practice Address - Phone:478-476-9285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036325207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000518207GMedicaid
GA52029199OtherBCBS OF GEORGIA
GA52029199OtherBCBS OF GEORGIA
GAP00175574Medicare PIN