Provider Demographics
NPI:1568509099
Name:SONG, JE (MD)
Entity Type:Individual
Prefix:
First Name:JE
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:P.O. BOX 1036
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-1036
Mailing Address - Country:US
Mailing Address - Phone:228-206-2681
Mailing Address - Fax:
Practice Address - Street 1:19424 SAUCIER LIZANA RD
Practice Address - Street 2:
Practice Address - City:SAUCIER
Practice Address - State:MS
Practice Address - Zip Code:39574-9667
Practice Address - Country:US
Practice Address - Phone:228-206-2681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17284207P00000X, 207ZP0105X, 208600000X, 208D00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04906363Medicaid
MS02000514Medicare ID - Type Unspecified
MS04906363Medicaid