Healthcare Provider Details

I. General information

NPI: 1568758688
Provider Name (Legal Business Name): KEVAN HEATH LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RAF LAKENHEATH 48 MDG/SGHC UNIT 5115
APO AE
09464-5115
US

IV. Provider business mailing address

48 MDG / RAF LAKENHEATH
APO NY
09461
US

V. Phone/Fax

Practice location:
  • Phone: 163-852-8124
  • Fax:
Mailing address:
  • Phone: 314-268-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number27546
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27546
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: