Healthcare Provider Details

I. General information

NPI: 1053424838
Provider Name (Legal Business Name): EDMOND MICHAEL YOUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 NW ENGLEWOOD CT #300
GLADSTONE MO
64118
US

IV. Provider business mailing address

305 NW ENGLEWOOD CT #300
GLADSTONE MO
64118
US

V. Phone/Fax

Practice location:
  • Phone: 816-453-7473
  • Fax: 816-453-1940
Mailing address:
  • Phone: 816-453-7473
  • Fax: 816-453-1940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number112656
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: