Provider Demographics
NPI:1710191572
Name:LONG, THOMAS CHARLES
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CHARLES
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:CHARLES
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:51 W MUNDHANK RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-9317
Mailing Address - Country:US
Mailing Address - Phone:847-551-9119
Mailing Address - Fax:847-551-9142
Practice Address - Street 1:51 W MUNDHANK RD
Practice Address - Street 2:
Practice Address - City:SOUTH BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-9317
Practice Address - Country:US
Practice Address - Phone:847-551-9119
Practice Address - Fax:847-551-9142
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30649000Medicaid
IL04112730546OtherAMA EDUCATION NUMBER
WI30649000Medicaid