Basic Information
| Provider Information | |||||||||
| NPI: | 1124067491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 343 ELM ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895034522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753236100 | ||||||||
| FaxNumber: | 7753236118 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 ELM ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895034522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753236100 | ||||||||
| FaxNumber: | 7753236118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 09/24/2012 | ||||||||
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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 | 207T00000X | 10771 | NV | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | CC7555 | 01 | NV | BLUE CROSS BLUE SHIELD | OTHER | 100502786 | 05 | NV | MEDICAID | 880167036A022 | 01 | NV | TRICARE | OTHER |