Healthcare Provider Details

I. General information

NPI: 1669977104
Provider Name (Legal Business Name): ZACHARY JAMES LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 N HALSTED ST
CHICAGO IL
60657-3419
US

IV. Provider business mailing address

3421 NORTHVIEW DR
JACKSON MS
39216-3112
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax: 773-388-8936
Mailing address:
  • Phone: 601-927-8822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.156666
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: