Provider Demographics
NPI:1730378423
Name:CHUNG M. SONG, MD, SC
Entity type:Organization
Organization Name:CHUNG M. SONG, MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUNG
Authorized Official - Middle Name:M
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-948-9661
Mailing Address - Street 1:2910 CHEROKEE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1609
Mailing Address - Country:US
Mailing Address - Phone:847-948-9661
Mailing Address - Fax:773-651-9655
Practice Address - Street 1:6202 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2029
Practice Address - Country:US
Practice Address - Phone:773-651-2188
Practice Address - Fax:773-651-9655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.617778207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068375Medicaid
IL210821Medicare PIN
IL036068375Medicaid