Provider Demographics
NPI:1629378005
Name:YOUNG ORTHOPAEDICS & SPORTS MEDICINE, PA
Entity Type:Organization
Organization Name:YOUNG ORTHOPAEDICS & SPORTS MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:904-230-2000
Mailing Address - Street 1:9191 R G SKINNER PARKWAY
Mailing Address - Street 2:SUITE #703
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9662
Mailing Address - Country:US
Mailing Address - Phone:904-232-2000
Mailing Address - Fax:904-230-6000
Practice Address - Street 1:9191 R.G. SKINNER PARKWAY
Practice Address - Street 2:SUITE 703
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9662
Practice Address - Country:US
Practice Address - Phone:904-232-2000
Practice Address - Fax:904-230-6000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 96716207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6686260001Medicare NSC