Provider Demographics
NPI:1437340692
Name:ELLEN SONG MD INC.
Entity Type:Organization
Organization Name:ELLEN SONG MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-748-8866
Mailing Address - Street 1:62 CORPORATE PARK
Mailing Address - Street 2:SUITE 235
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-3122
Mailing Address - Country:US
Mailing Address - Phone:949-748-8866
Mailing Address - Fax:949-748-8868
Practice Address - Street 1:62 CORPORATE PARK
Practice Address - Street 2:SUITE 235
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-3122
Practice Address - Country:US
Practice Address - Phone:949-748-8866
Practice Address - Fax:949-748-8868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86825207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty