=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972944684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK M. SONG M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2013
-----------------------------------------------------
Last Update Date | 07/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11920 GARVEY AVE
-----------------------------------------------------
City | EL MONTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91732-3514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-448-7575
-----------------------------------------------------
Fax | 626-448-8831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 S BROOKHURST RD STE 115
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92833-4471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-626-0700
-----------------------------------------------------
Fax | 714-626-0800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK MYUNGJAE SONG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-626-0700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------