Healthcare Provider Details

I. General information

NPI: 1174902514
Provider Name (Legal Business Name): ROBERT MICHAEL SONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 PELHAM PKWY S BLDG 6
BRONX NY
10461-1119
US

IV. Provider business mailing address

18 N BROADWAY UNIT 107
TARRYTOWN NY
10591-3223
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-5820
  • Fax:
Mailing address:
  • Phone: 631-901-8675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number298012
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: