Basic Information
Provider Information | |||||||||
NPI: | 1013112283 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUYNH | ||||||||
FirstName: | LONG | ||||||||
MiddleName: | HA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HUYNH | ||||||||
OtherFirstName: | LONG | ||||||||
OtherMiddleName: | HA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD., PH.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3988 | ||||||||
Address2: |   | ||||||||
City: | CARBONDALE | ||||||||
State: | IL | ||||||||
PostalCode: | 629023988 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185490752 | ||||||||
FaxNumber: | 6185290449 | ||||||||
Practice Location | |||||||||
Address1: | 405 W JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | CARBONDALE | ||||||||
State: | IL | ||||||||
PostalCode: | 629011462 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185490721 | ||||||||
FaxNumber: | 6185290449 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2007 | ||||||||
LastUpdateDate: | 11/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD600854844 | WA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 036149496 | IL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 214881 | 01 | IL | MULTI SPECIALTY GROUP PTAN | OTHER |