Provider Demographics
NPI:1053478297
Name:YONG JAE SONG MD INC
Entity Type:Organization
Organization Name:YONG JAE SONG MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YONG
Authorized Official - Middle Name:J
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-843-7772
Mailing Address - Street 1:6731 RIDGE RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5708
Mailing Address - Country:US
Mailing Address - Phone:440-843-7772
Mailing Address - Fax:440-845-0430
Practice Address - Street 1:6731 RIDGE RD
Practice Address - Street 2:SUITE 302
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5708
Practice Address - Country:US
Practice Address - Phone:440-843-7772
Practice Address - Fax:440-845-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0897589Medicaid
OH0897589Medicaid