=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437340692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLEN SONG MD INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2007
-----------------------------------------------------
Last Update Date | 08/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 62 CORPORATE PARK SUITE 235
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92606-3122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-748-8866
-----------------------------------------------------
Fax | 949-748-8868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62 CORPORATE PARK SUITE 235
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92606-3122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-748-8866
-----------------------------------------------------
Fax | 949-748-8868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELLEN TERESA SONG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-748-8866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A86825
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A86825
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------