Provider Demographics
NPI:1124081062
Name:SONG, SONG (MD)
Entity type:Individual
Prefix:DR
First Name:SONG
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:18 LOJKO DR
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-2298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:401-490-2141
Practice Address - Street 1:295 VARNUM AVE
Practice Address - Street 2:ANESTHETICS OF LOWELL, PC
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2134
Practice Address - Country:US
Practice Address - Phone:978-454-0941
Practice Address - Fax:978-458-0743
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA158907207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3205649Medicaid
H09855Medicare UPIN
MA3205649Medicaid