MEDICARE: STANTON L LONGENECKER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	ME49077	FL
2	207XS0114X	Adult Reconstructive Orthopaedic Surgery Physician	ME49077	FL
3	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	ME49077	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821092271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STANTON L LONGENECKER MD

Provider Business Mailing Address
First Line	:	11945 SAN JOSE BLVD STE 300
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-1627
Country	:	US
Telephone Number	:	904-396-1725
Fax Number	:	904-396-4893

Provider Business Practice Location Address
First Line	:	2 SHIRCLIFF WAY STE 300
Second Line	:	CREDENTIALING DEPARTMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4753
Country	:	US
Telephone Number	:	904-204-5000
Fax Number	:	904-204-4000

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	08/01/2019

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Directions to “ STANTON L LONGENECKER MD” Practice Location

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