Provider Demographics
NPI:1023057320
Name:LONGO, JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:LONGO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 W FOND DU LAC ST.
Mailing Address - Street 2:CHN MEDICAL CENTER - RIPON
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971
Mailing Address - Country:US
Mailing Address - Phone:920-748-7000
Mailing Address - Fax:920-748-7236
Practice Address - Street 1:1080 W FOND DU LAC ST.
Practice Address - Street 2:CHN MEDICAL CENTER - RIPON
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971
Practice Address - Country:US
Practice Address - Phone:920-748-7000
Practice Address - Fax:920-748-7236
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52559-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1023057320Medicaid
WI004160135Medicare PIN
IL213879Medicare PIN
ILIL2215Medicare PIN
ILIL2214Medicare PIN
IL213909Medicare PIN
IL2234136OtherBCBS
IL036115234Medicaid