Provider Demographics
NPI:1730445313
Name:SONG PLASTIC SURGERY, INC.
Entity type:Organization
Organization Name:SONG PLASTIC SURGERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-701-4454
Mailing Address - Street 1:4968 BOOTH CIR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3360
Mailing Address - Country:US
Mailing Address - Phone:949-701-4454
Mailing Address - Fax:949-701-4878
Practice Address - Street 1:4968 BOOTH CIR
Practice Address - Street 2:SUITE 105
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3360
Practice Address - Country:US
Practice Address - Phone:949-701-4454
Practice Address - Fax:949-701-4878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1024062086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA903AOtherMEDICARE PTAN
CACK861TOtherMEDICARE PTAN