Provider Demographics
NPI:1245222108
Name:BUTLER-MOO YOUNG, NICHOLE M (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:M
Last Name:BUTLER-MOO YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICHOLE
Other - Middle Name:M
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7411 LAKE ST STE 1120
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1882
Mailing Address - Country:US
Mailing Address - Phone:708-763-2328
Mailing Address - Fax:708-345-9984
Practice Address - Street 1:7411 LAKE ST STE 1120
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1882
Practice Address - Country:US
Practice Address - Phone:708-763-2328
Practice Address - Fax:708-345-9984
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099421207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099421Medicaid
ILH83198Medicare UPIN
ILF400119079Medicare PIN