Provider Demographics
NPI:1770102105
Name:IGENOME, INC.
Entity type:Organization
Organization Name:IGENOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:YU
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-896-2176
Mailing Address - Street 1:1835 CHESTNUT ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-3702
Mailing Address - Country:US
Mailing Address - Phone:267-896-2176
Mailing Address - Fax:
Practice Address - Street 1:1 WORLD TRADE CTR FL 8
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90831-0002
Practice Address - Country:US
Practice Address - Phone:267-896-2176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGOtherMEDICAID
MAPENDINGMedicaid
NJPENDINGMedicaid
PAPENDINGMedicaid
NYPENDINGMedicaid