Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 125069930 | IL |
NPI | 1083155303 |
---|---|
Provider Name | Andre Young Son |
First Address | Chicago, IL 60611-2908 |
Second Address | Chicago, IL 60611-2908 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2017 |
Last Update Date | 16/12/2018 |