1871753525 NPI number — DR. SHLEE SANG-HYUN SONG MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871753525 NPI number — DR. SHLEE SANG-HYUN SONG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SONG
Provider First Name:
SHLEE
Provider Middle Name:
SANG-HYUN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE
Provider Other First Name:
SANG-HYUN
Provider Other Middle Name:
SHAY
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871753525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8700 BEVERLY BLVD
Provider Second Line Business Mailing Address:
DEPT OF NEUROLOGY, THALIANS, SUITE E216
Provider Business Mailing Address City Name:
WEST HOLLYWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90048-1804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-423-5349
Provider Business Mailing Address Fax Number:
310-248-8038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8700 BEVERLY BLVD
Provider Second Line Business Practice Location Address:
DEPT OF NEUROLOGY, THALIANS, SUITE E216
Provider Business Practice Location Address City Name:
WEST HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-423-5349
Provider Business Practice Location Address Fax Number:
310-248-8038
Provider Enumeration Date:
06/16/2008

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: 2084V0102X , with the licence number:  D0067655 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084V0102X , with the licence number: MD037432 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084V0102X , with the licence number: A116747 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A116747 . This is a "THE MEDICAL BOARD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: D0067655 . This is a "MARYLAND BOARD OF PHYSICIANS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: MD037432 . This is a "DC HEALTH PROFESSIONAL LICENSING ADMINISTRATION, BOARD OF MEDICINE" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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