Healthcare Provider Details

I. General information

NPI: 1235167834
Provider Name (Legal Business Name): LONGCHENG SU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 05/13/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 S ROUTE 31
CRYSTAL LAKE IL
60014-8190
US

IV. Provider business mailing address

29624 NETWORK PL
CHICAGO IL
60673-1296
US

V. Phone/Fax

Practice location:
  • Phone: 779-220-5500
  • Fax:
Mailing address:
  • Phone: 608-756-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036-103793
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: