Provider Demographics
NPI:1528241775
Name:ALICE SONG M.D., A MED CORP
Entity type:Organization
Organization Name:ALICE SONG M.D., A MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-427-5409
Mailing Address - Street 1:2650 ELM AVE
Mailing Address - Street 2:108
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1651
Mailing Address - Country:US
Mailing Address - Phone:562-427-5409
Mailing Address - Fax:562-426-6321
Practice Address - Street 1:2650 ELM AVE
Practice Address - Street 2:108
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1651
Practice Address - Country:US
Practice Address - Phone:562-427-5409
Practice Address - Fax:562-426-6321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87752207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A877520Medicaid
A87752Medicare PIN
H72446Medicare UPIN