Provider Demographics
NPI:1700968047
Name:CHUNG, SONG SUCK (MD)
Entity Type:Individual
Prefix:MR
First Name:SONG
Middle Name:SUCK
Last Name:CHUNG
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 558
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:MD
Mailing Address - Zip Code:21153-0558
Mailing Address - Country:US
Mailing Address - Phone:410-582-9292
Mailing Address - Fax:410-582-9295
Practice Address - Street 1:1412 N CRAIN HWY
Practice Address - Street 2:SUITE 6A
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-9306
Practice Address - Country:US
Practice Address - Phone:410-582-9292
Practice Address - Fax:410-582-9295
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD14172207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD05740001OtherBLUE CHOICE
MDKFJ3OtherBLUE CROSS BLUE SHIELD
MDKFJ3OtherBLUE CROSS BLUE SHIELD
MD2275Medicare ID - Type Unspecified