Provider Demographics
NPI:1184117004
Name:SONG, BRENTON JAY SEUNG HOON (DO)
Entity type:Individual
Prefix:
First Name:BRENTON
Middle Name:JAY SEUNG HOON
Last Name:SONG
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 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:814-868-2529
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:4740 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2008
Practice Address - Country:US
Practice Address - Phone:814-454-3174
Practice Address - Fax:814-616-8002
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0214052084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOT018477Medicaid