MEDICARE: JINHYUK AUGUSTINE SONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1225779580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JINHYUK AUGUSTINE SONG

Provider Business Mailing Address
First Line	:	ATRIUM HEALTH WAKE FOREST BAPTIST DEPT OF PSYCHIATRY M
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-1087
Country	:	US
Telephone Number	:	336-716-4551
Fax Number	:

Provider Business Practice Location Address
First Line	:	ATRIUM HEALTH WAKE FOREST BAPTIST DEPT OF PSYCHIATRY M
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-1087
Country	:	US
Telephone Number	:	336-716-4551
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2022
Last Update Date	:	04/01/2022

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