Healthcare Provider Details

I. General information

NPI: 1114036027
Provider Name (Legal Business Name): ROGER CHARLES YOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 JEFFERSON AVE E160
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

262 MEADOWGROVE LN
MEMPHIS TN
38120-2611
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-1509
  • Fax:
Mailing address:
  • Phone: 802-658-4959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0420011205
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number49929
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: