Provider Demographics
NPI:1740233667
Name:LONGELLO, RALPH S (CRNA)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:S
Last Name:LONGELLO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6307
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5611
Practice Address - Country:US
Practice Address - Phone:864-455-7111
Practice Address - Fax:864-455-6441
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPRN801367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20031170OtherINDIVIDUAL SELECT HEALTH
SC576007863OtherCIGNA
SC576007863OtherBLUE CHOICE
SC20031911OtherSELECT HEALTH
SC576007863OtherBCBS
SC576007863OtherAETNA
SC576007863OtherUHC
SCAN0586Medicaid
SC430079699OtherMEDICARE RAILROAD
SCQ31010Medicare ID - Type UnspecifiedMEDICARE ID