Provider Demographics
NPI:1578870556
Name:MICHAEL E LONGEVIN MDSC
Entity Type:Organization
Organization Name:MICHAEL E LONGEVIN MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:LONGEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-692-5828
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-5828
Mailing Address - Fax:309-692-5904
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-5828
Practice Address - Fax:309-692-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-11
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072215208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
756760Medicare PIN