Provider Demographics
NPI:1114952066
Name:SONG, GI SUK (MD)
Entity Type:Individual
Prefix:
First Name:GI
Middle Name:SUK
Last Name:SONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2270
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12402-2270
Mailing Address - Country:US
Mailing Address - Phone:845-339-7582
Mailing Address - Fax:845-336-5616
Practice Address - Street 1:105 MARYS AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-338-2500
Practice Address - Fax:845-338-5616
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170312-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01232508Medicaid
NY071F82Medicare ID - Type Unspecified
NYE87497Medicare UPIN