Basic Information
| Provider Information | |||||||||
| NPI: | 1609894880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406845816 | ||||||||
| FaxNumber: | 4406845952 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168441700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 04/07/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 35-072144 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0304914 | 01 | OH | BCMH | OTHER | 2103477 | 05 | OH | MEDICAID | P00358878 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000203680 | 01 | OH | UNISON | OTHER | 000000503578 | 01 | OH | ANTHEM | OTHER | 1010340150001 | 05 | PA | MEDICAID | 1609894880 | 01 | MI | MI MEDICAID | OTHER | 732116 | 01 | OH | BUCKEYE | OTHER | 5253604 | 01 | OH | AETNA | OTHER | 364159 | 01 | OH | WELLCARE | OTHER |