Basic Information
| Provider Information | |||||||||
| NPI: | 1992724553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOUNGERMAN | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 N EDWARD ST | ||||||||
| Address2: | GSBLL | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625264163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178762857 | ||||||||
| FaxNumber: | 2178762874 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEMORIAL DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625266303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174242442 | ||||||||
| FaxNumber: | 2174249431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 09/04/2014 | ||||||||
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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 | 174400000X | 036084067 | IL | Y | Other Service Providers | Specialist |
No ID Information.