Provider Demographics
NPI:1366483471
Name:SONG, PAUL Y (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:Y
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 10050
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90267-7550
Mailing Address - Country:US
Mailing Address - Phone:213-744-1460
Mailing Address - Fax:213-744-1486
Practice Address - Street 1:2800 W 95TH ST
Practice Address - Street 2:CANCER CENTER
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2746
Practice Address - Country:US
Practice Address - Phone:708-423-6286
Practice Address - Fax:708-499-3842
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360903502085R0001X
CAG880142085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090350Medicaid
ILK26801Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAWG88014BMedicare PIN
F39113Medicare UPIN
CAAP525ZMedicare PIN
CAAP525YMedicare PIN
IL036090350Medicaid
CAWG88014CMedicare PIN
CAWG88014AMedicare PIN