Provider Demographics
NPI:1588610489
Name:YOUNG, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13005
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-3005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1317 N ELM ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1033
Practice Address - Country:US
Practice Address - Phone:336-274-4285
Practice Address - Fax:336-268-9062
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC164862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2087OtherPARTNERS
NC70523OtherMEDCOST
NC89796OtherBCBS OF NC DRI
NC8989811Medicaid
NC89811OtherBCBS
NC1600284OtherUNITED HEALTHCARE
NC1600284OtherUNITED HEALTHCARE
NC213419AMedicare ID - Type Unspecified