Healthcare Provider Details

I. General information

NPI: 1386642445
Provider Name (Legal Business Name): GINA K. SONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA M. SONG M.D.

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2455 DEAN ST SUITE A
ST CHARLES IL
60175-4830
US

IV. Provider business mailing address

2455 DEAN ST SUITE A
ST CHARLES IL
60175
US

V. Phone/Fax

Practice location:
  • Phone: 630-513-9160
  • Fax: 630-513-9617
Mailing address:
  • Phone: 630-513-9160
  • Fax: 630-513-9617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036104024
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: