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: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CLIFTON RD NE
ATLANTA GA
30322-1060
US

IV. Provider business mailing address

1405 CLIFTON RD NE
ATLANTA GA
30322-1060
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 Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number036.132063
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: