Healthcare Provider Details

I. General information

NPI: 1295711067
Provider Name (Legal Business Name): JOHN LONGANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SUPERIOR AVE
SHEBOYGAN WI
53081-1948
US

IV. Provider business mailing address

111 E WISCONSIN AVE STE 2000
MILWAUKEE WI
53202-4809
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6715
  • Fax:
Mailing address:
  • Phone: 414-290-6715
  • Fax: 414-290-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-059397
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number36059397
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-059397
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: