Healthcare Provider Details

I. General information

NPI: 1437340692
Provider Name (Legal Business Name): ELLEN SONG MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 CORPORATE PARK SUITE 235
IRVINE CA
92606-3122
US

IV. Provider business mailing address

62 CORPORATE PARK SUITE 235
IRVINE CA
92606-3122
US

V. Phone/Fax

Practice location:
  • Phone: 949-748-8866
  • Fax: 949-748-8868
Mailing address:
  • Phone: 949-748-8866
  • Fax: 949-748-8868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA86825
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA86825
License Number StateCA

VIII. Authorized Official

Name: DR. ELLEN TERESA SONG
Title or Position: OWNER
Credential: M.D.
Phone: 949-748-8866