Healthcare Provider Details

I. General information

NPI: 1316902802
Provider Name (Legal Business Name): DAE Y SONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 MEDICAL CENTER PKWY
SELMA AL
36701-6794
US

IV. Provider business mailing address

1100 MEDICAL CENTER PKWY
SELMA AL
36701-6794
US

V. Phone/Fax

Practice location:
  • Phone: 334-874-8787
  • Fax: 334-874-8780
Mailing address:
  • Phone: 334-874-8787
  • Fax: 334-874-8780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number00017689
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: