1053575340 NPI number — DR. MIN SOO SONG MD.,CM

Table of content: DR. MIN SOO SONG MD.,CM (NPI 1053575340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053575340 NPI number — DR. MIN SOO SONG MD.,CM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SONG
Provider First Name:
MIN SOO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD.,CM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053575340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 ERDMAN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEOMINSTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01453-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-466-7800
Provider Business Mailing Address Fax Number:
978-466-9333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 ERDMAN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEOMINSTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01453-1805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-466-7800
Provider Business Practice Location Address Fax Number:
978-466-9333
Provider Enumeration Date:
07/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  239085 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RT0003X , with the licence number: 248069 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1053575340 . This is a "HMO BLUE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 498955 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 951278-01 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 98493515 . This is a "AETNA NON HMO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0442974 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1053575340 . This is a "AETNA HMO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1053575340 . This is a "FALLON COMMUNITY HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: AA146200 . This is a "HARVARD PILGRIM HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 001093301 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1053575340 . This is a "EVERCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 110082569A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1053575340 . This is a "BCBS OF MASSACHUSETTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 30208701 . This is a "NH MEDICAID" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 3523061 . This is a "CIGNA HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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