Provider Demographics
NPI:1447207303
Name:SONG, SAM HWA (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:HWA
Last Name:SONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 3RD ST SE
Mailing Address - Street 2:150 & 200
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3702
Mailing Address - Country:US
Mailing Address - Phone:253-697-3550
Mailing Address - Fax:
Practice Address - Street 1:1408 3RD ST SE
Practice Address - Street 2:150 & 200
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3702
Practice Address - Country:US
Practice Address - Phone:253-697-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038499207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7024526OtherAETNA PROVIDER NUMBER
WA6688SOOtherREGENCE RIDER NUMBER
WA8265118Medicaid
WA0168702OtherL & I PROVIDER NUMBER
WA91120349445OtherKPS PROVIDER NUMBER
WA98372D004OtherTRICARE PROVIDER NUMBER
WA7024526OtherAETNA PROVIDER NUMBER