Provider Demographics
NPI:1053424838
Name:YOUNG, EDMOND MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:MICHAEL
Last Name:YOUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NW ENGLEWOOD CT #300
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118
Mailing Address - Country:US
Mailing Address - Phone:816-453-7473
Mailing Address - Fax:816-453-1940
Practice Address - Street 1:305 NW ENGLEWOOD CT #300
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118
Practice Address - Country:US
Practice Address - Phone:816-453-7473
Practice Address - Fax:816-453-1940
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1126562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
1328084Medicare ID - Type Unspecified
G60375Medicare UPIN