Basic Information
| Provider Information | |||||||||
| NPI: | 1952348039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4196 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319140196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066531102 | ||||||||
| FaxNumber: | 7066531203 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 19TH ST NW | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200363701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012794499 | ||||||||
| FaxNumber: | 3012794489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 08/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | D0057924 | MD | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 699111400 | 05 | MD | MEDICAID | KA80 | 01 | MD | B/C B/S | OTHER | 2849 | 01 | DC | B/C B/S | OTHER | J062 | 01 | MD | B/C B/S | OTHER |