Provider Demographics
NPI:1447728720
Name:SONG PROFESSIONAL SERVICES , PLLC
Entity type:Organization
Organization Name:SONG PROFESSIONAL SERVICES , PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:448-868-1971
Mailing Address - Street 1:POB 29650 DPT: 880423
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9650
Mailing Address - Country:US
Mailing Address - Phone:844-868-1971
Mailing Address - Fax:469-453-3374
Practice Address - Street 1:9811 W CHARLESTON BLVD # 2-641
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7528
Practice Address - Country:US
Practice Address - Phone:800-310-7334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV10771OtherNV MEDICAL LICENSE