Provider Demographics
NPI:1942373089
Name:YU, SONG YOL (DO)
Entity Type:Individual
Prefix:
First Name:SONG
Middle Name:YOL
Last Name:YU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:319 W DELAWARE ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:MI
Practice Address - Zip Code:49045-1106
Practice Address - Country:US
Practice Address - Phone:269-423-7028
Practice Address - Fax:269-423-8282
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101013501207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114993740Medicaid
MI700H060020OtherBCBSM
MI1942373089Medicaid
MIH56202Medicare UPIN
MI0H06012017Medicare PIN