Healthcare Provider Details

I. General information

NPI: 1558384214
Provider Name (Legal Business Name): TIMOTHY P LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N HIGHWAY 47
MARTHASVILLE MO
63357
US

IV. Provider business mailing address

901 PATIENTS FIRST DR
WASHINGTON MO
63090-4700
US

V. Phone/Fax

Practice location:
  • Phone: 636-433-5411
  • Fax: 636-433-2910
Mailing address:
  • Phone: 636-239-4100
  • Fax: 636-390-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9468
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: