Provider Demographics
NPI:1477731727
Name:LONGFELLOW, INC.
Entity Type:Organization
Organization Name:LONGFELLOW, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:EVERETT
Authorized Official - Last Name:LONGFELLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:740-392-4878
Mailing Address - Street 1:306 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3420
Mailing Address - Country:US
Mailing Address - Phone:740-392-4878
Mailing Address - Fax:740-392-6894
Practice Address - Street 1:306 E HIGH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3420
Practice Address - Country:US
Practice Address - Phone:740-392-4878
Practice Address - Fax:740-392-6894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1575261Q00000X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000503889OtherANTHEM PROVIDER #
OH1912935859OtherRENDERING PROVIDER'S NPI #
OH2719133Medicaid
OHLO9366411Medicare PIN
OH1912935859OtherRENDERING PROVIDER'S NPI #