Healthcare Provider Details

I. General information

NPI: 1710266770
Provider Name (Legal Business Name): MRS. STARR ANGELINE SONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2819 EMBASSY ROW 819
INDIANAPOLIS IN
46224
US

IV. Provider business mailing address

2819 EMBASSY ROW 819
INDIANAPOLIS IN
46224-2988
US

V. Phone/Fax

Practice location:
  • Phone: 317-400-7545
  • Fax:
Mailing address:
  • Phone: 317-400-7545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number2350-43-7769
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number2350-43-7769
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: