Healthcare Provider Details

I. General information

NPI: 1770718843
Provider Name (Legal Business Name): JUSTIN B LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 N DRUID HILLS RD NE
ATLANTA GA
30329-3117
US

IV. Provider business mailing address

2220 N DRUID HILLS RD NE
ATLANTA GA
30329-3117
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-6670
  • Fax:
Mailing address:
  • Phone: 404-785-6670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number76006
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number036.132063
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: