=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740273143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADFORD YOUNG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2005
-----------------------------------------------------
Last Update Date | 07/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2741 NAVARRE AVE STE 401
-----------------------------------------------------
City | OREGON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43616-3278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-693-7071
-----------------------------------------------------
Fax | 419-693-3051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2741 NAVARRE AVE STE 401
-----------------------------------------------------
City | OREGON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43616-3278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-693-7071
-----------------------------------------------------
Fax | 419-693-3051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35071273
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------