1144599572 NPI number — DR. JACK M. LONG & ASSOC., P.A.

Table of content: (NPI 1144599572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144599572 NPI number — DR. JACK M. LONG & ASSOC., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. JACK M. LONG & ASSOC., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144599572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 MAIDEN CHOICE LN
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
CATONSVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21228-5940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-744-5499
Provider Business Mailing Address Fax Number:
410-455-0894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 MAIDEN CHOICE LN
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CATONSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21228-5940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-744-5499
Provider Business Practice Location Address Fax Number:
410-455-0894
Provider Enumeration Date:
12/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
JACK
Authorized Official Middle Name:
MARTIN
Authorized Official Title or Position:
PSYCHOTHERAPIST
Authorized Official Telephone Number:
410-744-5499

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  03068 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q292JM . This is a "MEDICARE UNSPECIFIED" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: R7610001 . This is a "BCBS FEDERAL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 755011100 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 755011100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: R7610001 . This is a "BLUE CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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