Individual
DR. CHANG KI SONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
5401 N KNOXVILLE AVE, SUITE 217, PEORIA, IL 61614-5098
(309) 691-1092
(309) 689-6092
Mailing address
5401 N KNOXVILLE AVE, SUITE 209, PEORIA, IL 61614-5098
(309) 691-1092
(309) 689-6092
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
036060265
IL
2086S0129X
Vascular Surgery Physician
036060265
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036060265
—
IL
01
—
07221997
BLUE CROSS BLUE SHIELD
IL
Enumeration date
07/14/2006
Last updated
12/05/2008
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