Provider Demographics
NPI:1063442648
Name:LONG, JOHN JACOB (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JACOB
Last Name:LONG
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:800-862-9980
Mailing Address - Fax:314-362-1185
Practice Address - Street 1:2 PROGRESS POINT PKWY
Practice Address - Street 2:DEPT ANESTHESIOLOGY
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-2205
Practice Address - Country:US
Practice Address - Phone:800-862-9980
Practice Address - Fax:314-362-1185
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004020474207L00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209326909Medicaid