1700968047 NPI number — MR. SONG SUCK CHUNG 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 1700968047 NPI number — MR. SONG SUCK CHUNG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHUNG
Provider First Name:
SONG
Provider Middle Name:
SUCK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1700968047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 558
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEVENSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21153-0558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-582-9292
Provider Business Mailing Address Fax Number:
410-582-9295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1412 N CRAIN HWY
Provider Second Line Business Practice Location Address:
SUITE 6A
Provider Business Practice Location Address City Name:
GLEN BURNIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21061-9306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-582-9292
Provider Business Practice Location Address Fax Number:
410-582-9295
Provider Enumeration Date:
10/19/2006

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: 207VG0400X , with the licence number:  D14172 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05740001 . This is a "BLUE CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: KFJ3 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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