1932730256 NPI number — CEREESA E. LONGEST MD SC

Table of content: (NPI 1932730256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932730256 NPI number — CEREESA E. LONGEST MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEREESA E. LONGEST MD SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932730256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 135
Provider Second Line Business Mailing Address:
117 S COOK STREET
Provider Business Mailing Address City Name:
BARRINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60010-4311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-253-4040
Provider Business Mailing Address Fax Number:
847-787-1489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 WEST CENTRAL ROAD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
ARLINGTON HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60005-2465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-253-4040
Provider Business Practice Location Address Fax Number:
847-253-3028
Provider Enumeration Date:
01/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
LONGEST
Authorized Official First Name:
CEREESA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
847-253-4040

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036-090336 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1467438341 . This is a "TYPE 1 NPI" identifier . This identifiers is of the category "OTHER".




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