Provider Demographics
NPI:1164914263
Name:SONG, MIA (DO)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:267-339-7843
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:600 EVERGREEN DR STE 201
Practice Address - Street 2:
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-1053
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:267-479-1321
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS021654208100000X
NJ25MB11516200208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation