Healthcare Provider Details

I. General information

NPI: 1518947530
Provider Name (Legal Business Name): EDWARD W SONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 E MELROSE ST STE 101-103
GILBERT AZ
85297-1001
US

IV. Provider business mailing address

PO BOX 80217
PHOENIX AZ
85060-0217
US

V. Phone/Fax

Practice location:
  • Phone: 602-648-5444
  • Fax: 602-772-3801
Mailing address:
  • Phone: 602-385-2115
  • Fax: 480-418-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number33859
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number33859
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: