=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891115671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SONG HEART AND VASCULAR PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2014
-----------------------------------------------------
Last Update Date | 04/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13656 39TH AVE 2ND FL
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-5598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-886-7575
-----------------------------------------------------
Fax | 718-886-7574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 153 CHARLOTTE PL
-----------------------------------------------------
City | ENGLEWOOD CLIFFS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07632-1616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-207-2650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. JASON SONG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-207-2650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 240614
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------