Basic Information
| Provider Information | |||||||||
| NPI: | 1679773212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | LIN KAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KAM | ||||||||
| OtherFirstName: | TRICIA | ||||||||
| OtherMiddleName: | LIN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 94-1480 MOANIANI ST | ||||||||
| Address2: | |||||||||
| City: | WAIPAHU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967974632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084323100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 94-1480 MOANIANI ST | ||||||||
| Address2: | |||||||||
| City: | WAIPAHU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967974632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084323100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A89908 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | MD14420 | HI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0000272153 | 01 | HI | HMSA | OTHER | 02143324 | 01 | HI | UNIVERSITY HEALTH ALLIANCE (UHA) | OTHER | 61317600 | 01 | HI | ALOHACARE QUEST PLAN (QALC) | OTHER | 61317601 | 01 | HI | MEDICAID DSS | OTHER |