Healthcare Provider Details

I. General information

NPI: 1679686679
Provider Name (Legal Business Name): SCOTT D. LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST DEPARTMENT OF RADIOLOGY
SPRINGFIELD IL
62702-5324
US

IV. Provider business mailing address

111 OAKWOOD RD
EAST PEORIA IL
61611-1853
US

V. Phone/Fax

Practice location:
  • Phone: 217-544-6464
  • Fax: 217-525-5671
Mailing address:
  • Phone: 309-740-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-091122
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number036091122
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: