Healthcare Provider Details

I. General information

NPI: 1801890686
Provider Name (Legal Business Name): HERBERT W LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 RIVER DR
IRVINE KY
40336-1272
US

IV. Provider business mailing address

PO BOX 936
LONDON KY
40743-0936
US

V. Phone/Fax

Practice location:
  • Phone: 606-723-0399
  • Fax: 606-723-0379
Mailing address:
  • Phone: 606-330-7818
  • Fax: 606-330-7825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31482
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: