Provider Demographics
NPI:1154563880
Name:LAURA L. LONG M.D., S.C.
Entity type:Organization
Organization Name:LAURA L. LONG M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-882-9119
Mailing Address - Street 1:122 S MICHIGAN AVE
Mailing Address - Street 2:SUITE 1406
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-6191
Mailing Address - Country:US
Mailing Address - Phone:312-882-9119
Mailing Address - Fax:312-663-3796
Practice Address - Street 1:122 S MICHIGAN AVE
Practice Address - Street 2:SUITE 1406
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-6191
Practice Address - Country:US
Practice Address - Phone:312-882-9119
Practice Address - Fax:312-663-3796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361147932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1518012590OtherNPI