Chang Ki Song, MD

Primary specialty

Surgery PhysicianTaxonomy code 208600000X

License

036060265 Issued in IL

Practice address

5401 N Knoxville Ave
Suite 217
Peoria, IL 61614-5098

Phone

(309) 691-1092

Fax

(309) 689-6092

NPI assigned

Jul 14, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• Dr. C K Song Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152835200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1228435200000",
    "number": "1609892728",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5401 N KNOXVILLE AVE",
            "address_2": "SUITE 209",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616145098",
            "telephone_number": "309-691-1092",
            "fax_number": "309-689-6092"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5401 N KNOXVILLE AVE",
            "address_2": "SUITE 217",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616145098",
            "telephone_number": "309-691-1092",
            "fax_number": "309-689-6092"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SONG",
        "first_name": "CHANG",
        "middle_name": "KI",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-07-14",
        "last_updated": "2008-12-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "IL",
            "license": "036060265",
            "primary": true
        },
        {
            "code": "2086S0129X",
            "taxonomy_group": "",
            "desc": "Surgery, Vascular Surgery",
            "state": "IL",
            "license": "036060265",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "036060265",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "07221997",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "C",
            "last_name": "SONG",
            "middle_name": "K",
            "prefix": "DR.",
            "credential": "MD",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Surgery Physician in Peoria, IL
• Providers in Peoria, IL by specialty
• Surgery Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 5, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.