Healthcare Provider Details

I. General information

NPI: 1770102105
Provider Name (Legal Business Name): IGENOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WORLD TRADE CTR FL 8
LONG BEACH CA
90831-0002
US

IV. Provider business mailing address

1835 CHESTNUT ST APT 3R
PHILADELPHIA PA
19103-3702
US

V. Phone/Fax

Practice location:
  • Phone: 267-896-2176
  • Fax:
Mailing address:
  • Phone: 267-896-2176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: YU SONG
Title or Position: CEO
Credential:
Phone: 267-896-2176