Basic Information
| Provider Information | |||||||||
| NPI: | 1164411591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | HYE YOUNG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4014538220 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4014538220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 209954 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 10642 | RI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD10642 | RI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0161853 | 01 | MASSMEDICAID | OTHER | 3080787 | 01 | CIGNA | OTHER | 000000001988 | 01 | NHPRI | OTHER | 243021 | 01 | RIHPILGRIM | OTHER | 300123642 | 01 | RAILROAD MEDICARE | OTHER | 003117232 | 01 | CT MED ASSISTANCE | OTHER | 7009119 | 01 | RIMEDICAL ASSISTANCE | OTHER | 010642 | 01 | TUFTS | OTHER | 1650203 | 01 | UNITEDHEALTHPLANS | OTHER | 0161853 | 01 | HEALTHYSTART | OTHER | 007009120 | 01 | HOSPITALPIN | OTHER | 408549 | 01 | BLUECHIP | OTHER | 10642 | 01 | BLUESHIELD | OTHER |