Basic Information
| Provider Information | |||||||||
| NPI: | 1952832719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | MINGJUN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MBBS, MRCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 ROTARY CIR STE 225 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172784427 | ||||||||
| FaxNumber: | 2038633446 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 ROTARY CIR STE 225 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172784427 | ||||||||
| FaxNumber: | 2038633446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2017 | ||||||||
| LastUpdateDate: | 06/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.