Healthcare Provider Details

I. General information

NPI: 1679712640
Provider Name (Legal Business Name): YOUNG SONG D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MILLER RD
STERLING IL
61081-1252
US

IV. Provider business mailing address

101 E MILLER RD
STERLING IL
61081-1252
US

V. Phone/Fax

Practice location:
  • Phone: 815-625-4790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036132647
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: