Healthcare Provider Details

I. General information

NPI: 1790757854
Provider Name (Legal Business Name): GARY A YOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E WESTERN RESERVE RD
POLAND OH
44514-3358
US

IV. Provider business mailing address

715 E WESTERN RESERVE RD
POLAND OH
44514-3358
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-3204
  • Fax: 330-729-9316
Mailing address:
  • Phone: 330-726-3204
  • Fax: 330-729-9316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35046446
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: