Healthcare Provider Details

I. General information

NPI: 1316373418
Provider Name (Legal Business Name): JOHN RICHARD YOUNG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-4021
  • Fax: 248-898-1473
Mailing address:
  • Phone: 947-522-0865
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006756
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: