Provider Demographics
NPI:1669406088
Name:SONG, KUNCHANG (MD)
Entity type:Individual
Prefix:
First Name:KUNCHANG
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 1:200 OLD PALISADE RD APT 30D
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-7063
Mailing Address - Country:US
Mailing Address - Phone:201-916-0154
Mailing Address - Fax:
Practice Address - Street 1:7600 RIVER RD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-6217
Practice Address - Country:US
Practice Address - Phone:201-520-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425765207ZC0500X, 207ZP0102X
NY247217207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology