Provider Demographics
NPI:1609892728
Name:SONG, CHANG KI (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:KI
Last Name:SONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:K
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-691-1092
Mailing Address - Fax:309-689-6092
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 217
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-691-1092
Practice Address - Fax:309-689-6092
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060265208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060265Medicaid
IL07221997OtherBLUE CROSS BLUE SHIELD
371366500OtherEIN
C03578Medicare UPIN
IL036060265Medicaid