Provider Demographics
NPI:1538396726
Name:SONG, SHIWEN (MD)
Entity type:Individual
Prefix:
First Name:SHIWEN
Middle Name:
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 1:1439 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3200
Mailing Address - Country:US
Mailing Address - Phone:312-823-0657
Mailing Address - Fax:224-588-9941
Practice Address - Street 1:1351 BARCLAY BLVD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089
Practice Address - Country:US
Practice Address - Phone:224-588-9940
Practice Address - Fax:224-588-9941
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103106207ZP0102X
IL36121319207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36121319Medicaid