Provider Demographics
NPI:1427581446
Name:SONG, BO (MD)
Entity Type:Individual
Prefix:DR
First Name:BO
Middle Name:
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 1:6560 FANNIN ST STE 1878
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2752
Mailing Address - Country:US
Mailing Address - Phone:713-441-5189
Mailing Address - Fax:713-441-5189
Practice Address - Street 1:6560 FANNIN ST STE 1878
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2752
Practice Address - Country:US
Practice Address - Phone:713-441-5189
Practice Address - Fax:713-441-5189
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021022115208100000X
TXT70492081S0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200045307Medicaid
TX1427581446OtherNPI