MEDICARE: DR. CHARLES H SONG M.D.

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	174400000X	Specialist	G23461	CA
2	2080P0201X	Pediatric Allergy/Immunology Physician	G23461	CA

General Provider Information

NPI Number	:	1790792869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES H SONG M.D.

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 MEDICAL PLAZA SUITE 265
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-6814
Country	:	US
Telephone Number	:	310-825-0867
Fax Number	:

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/05/2018

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