1801890686 NPI number — HERBERT W LONG MD

Table of content: HERBERT W LONG MD (NPI 1801890686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801890686 NPI number — HERBERT W LONG MD

Organization/Personal Information

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

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:
1801890686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40743-0936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-330-7818
Provider Business Mailing Address Fax Number:
606-330-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
417 RIVER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40336-1272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-723-0399
Provider Business Practice Location Address Fax Number:
606-723-0379
Provider Enumeration Date:
06/09/2005

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: 207Q00000X , with the licence number:  31482 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 61-1341297 . This is a "TRICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 5211107 . This is a "AETNA ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000889063 . This is a "HUMANA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64314826 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000052184 . This is a "ANTHEM BCBS ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 01-00767 . This is a "UNITED HEATLH CARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1166070 . This is a "CHA HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2768 . This is a "BLUEGRASS FAMILY HEALTH" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 35001262 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1532269 . This is a "UMWA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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