Healthcare Provider Details

I. General information

NPI: 1053564732
Provider Name (Legal Business Name): TAE H SONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 JOHNSON ST
HOLLYWOOD FL
33021-5421
US

IV. Provider business mailing address

2900 CORPORATE WAY DOOR D
MIRAMAR FL
33025-3925
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-7750
  • Fax: 954-276-0280
Mailing address:
  • Phone: 954-276-5603
  • Fax: 954-276-0357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME165335
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: