Basic Information
| Provider Information | |||||||||
| NPI: | 1093714362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | KUM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13904 LAKESHORE BLVD | ||||||||
| Address2: | STE 410 | ||||||||
| City: | HUDSON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346671481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278625489 | ||||||||
| FaxNumber: | 7278620397 | ||||||||
| Practice Location | |||||||||
| Address1: | 13904 LAKESHORE BLVD | ||||||||
| Address2: | STE 410 | ||||||||
| City: | HUDSON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346671481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278625489 | ||||||||
| FaxNumber: | 7278620397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 02/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | ME0048660 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 063864100 | 05 | FL | MEDICAID |