Healthcare Provider Details

I. General information

NPI: 1013628171
Provider Name (Legal Business Name): JOHN ALAN LONGMIRE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 12/09/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 E WALNUT ST
CARBONDALE IL
62901-5007
US

IV. Provider business mailing address

2401 W MAIN ST ATTN CARBONDALE CBOC
MARION IL
62959-1188
US

V. Phone/Fax

Practice location:
  • Phone: 618-351-1031
  • Fax: 618-351-1107
Mailing address:
  • Phone: 618-997-5311
  • Fax: 618-351-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: