=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982875084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURK T YOUNG MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2008
-----------------------------------------------------
Last Update Date | 04/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 N 100 W SUITE 201
-----------------------------------------------------
City | VERNAL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84078-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-789-7845
-----------------------------------------------------
Fax | 435-789-7851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 N 100 W SUITE 201
-----------------------------------------------------
City | VERNAL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84078-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-789-7845
-----------------------------------------------------
Fax | 435-789-7851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | DR. BURK TEAL YOUNG
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 435-789-7845
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 343005-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------