Basic Information
| Provider Information | |||||||||
| NPI: | 1114952066 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | GI | ||||||||
| MiddleName: | SUK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2270 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124022270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453397582 | ||||||||
| FaxNumber: | 8453365616 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 MARYS AVE | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453382500 | ||||||||
| FaxNumber: | 8453385616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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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 | 2085R0202X | 170312-1 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01232508 | 05 | NY | MEDICAID |