Healthcare Provider Details

I. General information

NPI: 1457222895
Provider Name (Legal Business Name): GRACE SINAE SONG AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 WASHINGTON ST
BOSTON MA
02111-1521
US

IV. Provider business mailing address

8 9TH ST APT 501
MEDFORD MA
02155-5144
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-9190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberAUD100201
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: