Provider Demographics
NPI:1730259177
Name:SONG, YOUNG S (DC)
Entity type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:S
Last Name:SONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 ROGERS AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4594
Mailing Address - Country:US
Mailing Address - Phone:410-480-2331
Mailing Address - Fax:410-480-2337
Practice Address - Street 1:3201 ROGERS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4594
Practice Address - Country:US
Practice Address - Phone:410-480-2331
Practice Address - Fax:410-480-2337
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02136111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD001H847OtherBCBS OF DC
MD618848-01OtherBCBS OF MD
MD402969100Medicaid
MD574M889FMedicare ID - Type Unspecified
MD618848-01OtherBCBS OF MD