Healthcare Provider Details

I. General information

NPI: 1568509099
Provider Name (Legal Business Name): JE SONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19424 SAUCIER LIZANA RD
SAUCIER MS
39574-9667
US

IV. Provider business mailing address

P.O. BOX 1036
PICAYUNE MS
39466-1036
US

V. Phone/Fax

Practice location:
  • Phone: 228-206-2681
  • Fax:
Mailing address:
  • Phone: 228-206-2681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number17284
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number17284
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number17284
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number17284
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number17284
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: