1003973272 NPI number — RANDI J. LONG M.D.

Table of content: WANDA EVELYN N.P. (NPI 1912097015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003973272 NPI number — RANDI J. LONG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONG
Provider First Name:
RANDI
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DIXON
Provider Other First Name:
RANDI
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003973272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33717 WOODWARD AVE STE 416
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48009-0913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-809-1227
Provider Business Mailing Address Fax Number:
248-809-1228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 W 13 MILE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-809-1227
Provider Business Practice Location Address Fax Number:
248-809-1228
Provider Enumeration Date:
01/03/2007

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: 174400000X , with the licence number:  4301056088 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 4301056088 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3480240 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com