Basic Information
| Provider Information | |||||||||
| NPI: | 1821092271 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONGENECKER | ||||||||
| FirstName: | STANTON | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11945 SAN JOSE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322231627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043961725 | ||||||||
| FaxNumber: | 9043964893 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 SHIRCLIFF WAY STE 300 | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042045000 | ||||||||
| FaxNumber: | 9042044000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 08/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME49077 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | ME49077 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XX0005X | ME49077 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 062862000 | 05 | FL | MEDICAID |