MEDICARE: MRS. GINA K. SONG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	036104024	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4532123	OTHER	IL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386642445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GINA K. SONG M.D.

Provider Business Mailing Address
First Line	:	2455 DEAN ST
Second Line	:	SUITE A
City	:	ST CHARLES
State	:	IL
Zip	:	60175
Country	:	US
Telephone Number	:	630-513-9160
Fax Number	:	630-513-9617

Provider Business Practice Location Address
First Line	:	2455 DEAN ST
Second Line	:	SUITE A
City	:	ST CHARLES
State	:	IL
Zip	:	60175-4830
Country	:	US
Telephone Number	:	630-513-9160
Fax Number	:	630-513-9617

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	12/28/2009

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