Basic Information
| Provider Information | |||||||||
| NPI: | 1972700656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | JAEKYUNG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 914 S SCHEUBER RD | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603308976 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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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 | 208M00000X | MD60377532 | WA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | MD60377532 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.