Provider Demographics
NPI:1033416151
Name:LONG, JASON (MD)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 N LASALLE ST
Mailing Address - Street 2:2811
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-6000
Mailing Address - Country:US
Mailing Address - Phone:312-315-6502
Mailing Address - Fax:
Practice Address - Street 1:5841 S. MARYLAND AVE
Practice Address - Street 2:UNIVERSITY OF CHICAGO HOSPITALS
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-702-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117184208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery