Provider Demographics
NPI:1952399511
Name:YOUNG, ROGER (NP)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 W WHITTAKER ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1917
Mailing Address - Country:US
Mailing Address - Phone:618-548-3740
Mailing Address - Fax:618-548-3705
Practice Address - Street 1:1250 W WHITTAKER ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1917
Practice Address - Country:US
Practice Address - Phone:618-548-3740
Practice Address - Fax:618-548-3705
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041255812363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110230526OtherRAILROAD MEDICARE
IL207988OtherGRP MEDICARE NUMBER
ILCJ2166OtherRR MEDICARE GROUP NUMBER
IL500025714OtherRAILROAD MEDICARE NUMBER
IL208959OtherGRP MEDICARE NUMBER
IL110230526OtherRAILROAD MEDICARE
IL500025714OtherRAILROAD MEDICARE NUMBER
ILCJ2166OtherRR MEDICARE GROUP NUMBER
IL207988OtherGRP MEDICARE NUMBER