Healthcare Provider Details

I. General information

NPI: 1942681101
Provider Name (Legal Business Name): XUYANG SONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2015
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 S HIGHLAND AVE STE 204C
LOMBARD IL
60148-6193
US

IV. Provider business mailing address

1919 S HIGHLAND AVE STE 204C
LOMBARD IL
60148-6193
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-4662
  • Fax: 708-613-4319
Mailing address:
  • Phone: 708-848-4662
  • Fax: 708-613-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036.157676
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number323567
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: