Basic Information
Provider Information | |||||||||
NPI: | 1922099084 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SONG | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | K. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 SW 10TH AVE | ||||||||
Address2: | MEDICAL STAFF SERVICES | ||||||||
City: | TOPEKA | ||||||||
State: | KS | ||||||||
PostalCode: | 666041301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7853546241 | ||||||||
FaxNumber: | 7852704343 | ||||||||
Practice Location | |||||||||
Address1: | 2660 SW 3RD ST | ||||||||
Address2: |   | ||||||||
City: | TOPEKA | ||||||||
State: | KS | ||||||||
PostalCode: | 666062442 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7853680778 | ||||||||
FaxNumber: | 7853680739 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2005 | ||||||||
LastUpdateDate: | 11/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 036111342 | IL | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 207T00000X | 04-44072 | KS | N |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   | 207T00000X | 036-111342 | IL | Y |   | Allopathic & Osteopathic Physicians | Neurological Surgery |   |
No ID Information.