Provider Demographics
NPI:1124067491
Name:SONG, MICHAEL H (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:SONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 ELM ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4522
Mailing Address - Country:US
Mailing Address - Phone:775-323-6100
Mailing Address - Fax:775-323-6118
Practice Address - Street 1:343 ELM ST
Practice Address - Street 2:SUITE 202
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4522
Practice Address - Country:US
Practice Address - Phone:775-323-6100
Practice Address - Fax:775-323-6118
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10771207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC7555OtherBLUE CROSS BLUE SHIELD
NV100502786Medicaid
NV880167036A022OtherTRICARE
NV880167036A022OtherTRICARE
NVCC7555OtherBLUE CROSS BLUE SHIELD
NVP00296527Medicare ID - Type UnspecifiedRR MEDICARE