Provider Demographics
NPI:1053575340
Name:SONG, MIN SOO (MD,CM)
Entity type:Individual
Prefix:DR
First Name:MIN SOO
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:MD,CM
Other - Prefix:
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Mailing Address - Street 1:105 ERDMAN WAY
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-1805
Mailing Address - Country:US
Mailing Address - Phone:978-466-7800
Mailing Address - Fax:978-466-9333
Practice Address - Street 1:105 ERDMAN WAY
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-1805
Practice Address - Country:US
Practice Address - Phone:978-466-7800
Practice Address - Fax:978-466-9333
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239085207RG0100X
NY248069207RT0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1053575340OtherHMO BLUE
MA498955OtherTUFTS
MA951278-01OtherNETWORK HEALTH
MA98493515OtherAETNA NON HMO
MA0442974OtherNEIGHBORHOOD HEALTH PLAN
MA1053575340OtherAETNA HMO
MA1053575340OtherFALLON COMMUNITY HEALTH CARE
MAAA146200OtherHARVARD PILGRIM HEALTH CARE
MA001093301OtherRAILROAD MEDICARE
MA1053575340OtherEVERCARE
MA110082569AMedicaid
MA1053575340OtherBCBS OF MASSACHUSETTS
NH30208701OtherNH MEDICAID
MA3523061OtherCIGNA HEALTH CARE
MA001093301Medicare PIN