Healthcare Provider Details

I. General information

NPI: 1366490963
Provider Name (Legal Business Name): BURK TEAL YOUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/07/2023
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S 5TH ST
DOUGLAS WY
82633-2434
US

IV. Provider business mailing address

111 S 5TH ST
DOUGLAS WY
82633-2434
US

V. Phone/Fax

Practice location:
  • Phone: 307-358-2122
  • Fax: 307-358-7382
Mailing address:
  • Phone: 307-358-2122
  • Fax: 307-358-7382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number11378A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: