Healthcare Provider Details

I. General information

NPI: 1124238878
Provider Name (Legal Business Name): GUY THOMAS YOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 N. SEVENTH ST.
CORDELE GA
31015
US

IV. Provider business mailing address

PO BOX 5007
CORDELE GA
31010-5007
US

V. Phone/Fax

Practice location:
  • Phone: 229-276-3100
  • Fax: 229-271-4654
Mailing address:
  • Phone: 229-276-3100
  • Fax: 229-271-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0101239107
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number060900
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: