Healthcare Provider Details

I. General information

NPI: 1972700656
Provider Name (Legal Business Name): JAEKYUNG SONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 S SCHEUBER RD
CENTRALIA WA
98531
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-330-8976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD60377532
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60377532
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: