Healthcare Provider Details

I. General information

NPI: 1730101759
Provider Name (Legal Business Name): ROBERT THEODORE LONGSHORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 US HWY 42 W
WARSAW KY
41095-9323
US

IV. Provider business mailing address

2546 KEARNEY COURT
LAKESIDE PARK KY
41017-2180
US

V. Phone/Fax

Practice location:
  • Phone: 859-567-1591
  • Fax: 859-567-1592
Mailing address:
  • Phone: 859-344-8116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12488
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: