Healthcare Provider Details

I. General information

NPI: 1063442648
Provider Name (Legal Business Name): JOHN JACOB LONG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 04/17/2025
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PROGRESS POINT PKWY DEPT ANESTHESIOLOGY
O FALLON MO
63368-2205
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 800-862-9980
  • Fax: 314-362-1185
Mailing address:
  • Phone: 800-862-9980
  • Fax: 314-362-1185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2004020474
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: