Provider Demographics
NPI:1710914999
Name:SONG, CHUNG (MD)
Entity Type:Individual
Prefix:
First Name:CHUNG
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 1:2910 CHEROKEE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1609
Mailing Address - Country:US
Mailing Address - Phone:773-651-2188
Mailing Address - Fax:773-651-9655
Practice Address - Street 1:6202 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2029
Practice Address - Country:US
Practice Address - Phone:773-651-2188
Practice Address - Fax:773-651-9655
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068375207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068375Medicaid
IL210821Medicare PIN
928260Medicare ID - Type Unspecified
IL036068375Medicaid