Provider Demographics
NPI:1679020119
Name:BAEK, SONG I
Entity type:Individual
Prefix:
First Name:SONG
Middle Name:I
Last Name:BAEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 PARKWAY AVE STE E
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9349
Mailing Address - Country:US
Mailing Address - Phone:574-218-7131
Mailing Address - Fax:
Practice Address - Street 1:1004 PARKWAY AVE STE E
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9349
Practice Address - Country:US
Practice Address - Phone:574-218-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006583A363LF0000X
IN28231893A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily