1003902875 NPI number — TIM LONG PT

Table of content: TIM LONG PT (NPI 1003902875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003902875 NPI number — TIM LONG PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG
Provider First Name:
TIM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LONG
Provider Other First Name:
TIMOTHY
Provider Other Middle Name:
ALAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1003902875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
430 MORTON PLANT ST
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33756-3398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-298-5230
Provider Business Mailing Address Fax Number:
727-298-5205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 MORTON PLANT ST
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33756-3398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-298-5230
Provider Business Practice Location Address Fax Number:
727-298-5205
Provider Enumeration Date:
10/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT6384 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)