Provider Demographics
NPI:1386642445
Name:SONG, GINA K (MD)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:K
Last Name:SONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:GINA
Other - Middle Name:M
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2455 DEAN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175
Mailing Address - Country:US
Mailing Address - Phone:630-513-9160
Mailing Address - Fax:630-513-9617
Practice Address - Street 1:2455 DEAN ST
Practice Address - Street 2:SUITE A
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-4830
Practice Address - Country:US
Practice Address - Phone:630-513-9160
Practice Address - Fax:630-513-9617
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104024208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4532123OtherBCBS
IL036104024Medicaid
IL036104024Medicaid
ILH95434Medicare UPIN