Provider Demographics
NPI:1255891529
Name:SONG, GRACE (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 RED BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-8222
Mailing Address - Country:US
Mailing Address - Phone:330-780-0102
Mailing Address - Fax:
Practice Address - Street 1:6450 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4882
Practice Address - Country:US
Practice Address - Phone:843-818-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.142992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program