Basic Information
| Provider Information | |||||||||
| NPI: | 1700345659 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | BURCH 221 | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701440 | ||||||||
| FaxNumber: | 8475701442 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | BURCH 221 | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475701440 | ||||||||
| FaxNumber: | 8475701442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2019 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085007006 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.