Basic Information
| Provider Information | |||||||||
| NPI: | 1265437230 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONGO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3880 SALEM LAKE DR | ||||||||
| Address2: | STE F | ||||||||
| City: | LONG GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600475292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477192220 | ||||||||
| FaxNumber: | 8477192265 | ||||||||
| Practice Location | |||||||||
| Address1: | 3880 SALEM LAKE DR | ||||||||
| Address2: | STE F | ||||||||
| City: | LONG GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600475292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477192220 | ||||||||
| FaxNumber: | 8477192265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 036089997 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 036089997 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036089997 | 05 | IL | MEDICAID | BL4333578 | 01 | IL | DEA | OTHER |