=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720037005
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOBBY YOUNG JOE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2006
-----------------------------------------------------
Last Update Date | 04/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13615 OLD HIGHWAY 61 NORTH HARRAH'S TAKE CARE HEALTH AND WELLNESS CLINIC
-----------------------------------------------------
City | ROBINSONVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-357-3264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7630 PROUD LAND DR
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38119-9140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-754-2988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 13992
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 9626
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------