Healthcare Provider Details

I. General information

NPI: 1376283036
Provider Name (Legal Business Name): PHILIP SONG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3134 N CLARK ST
CHICAGO IL
60657-4414
US

IV. Provider business mailing address

50 E BELLEVUE PL APT 2006
CHICAGO IL
60611-6119
US

V. Phone/Fax

Practice location:
  • Phone: 773-880-9722
  • Fax: 773-880-9723
Mailing address:
  • Phone: 412-641-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036175882
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: