Provider Demographics
NPI:1740205921
Name:KO, SONG-CHU (MD)
Entity Type:Individual
Prefix:
First Name:SONG-CHU
Middle Name:
Last Name:KO
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:PO BOX 3830
Mailing Address - Street 2:
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96932-3830
Mailing Address - Country:US
Mailing Address - Phone:671-645-5500
Mailing Address - Fax:671-645-5549
Practice Address - Street 1:133 ROUTE 3
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6544
Practice Address - Country:US
Practice Address - Phone:671-645-5500
Practice Address - Fax:671-645-5549
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061833A2085R0001X
GUM-19152085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000711556OtherANTHEM PROVIDER NUMBER
IN200826200Medicaid
INM400048580Medicare PIN
IN719710SMedicare PIN
IN200826200Medicaid