Healthcare Provider Details

I. General information

NPI: 1750465217
Provider Name (Legal Business Name): JOHN LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 STATE ST
BANGOR ME
04401-6616
US

IV. Provider business mailing address

300 PROFESSIONAL DR
SCARBOROUGH ME
04074-8433
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-8305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number008259
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number008259
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number008259
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number008259
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number008259
License Number StateME
# 6
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number008259
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: