Healthcare Provider Details

I. General information

NPI: 1912924473
Provider Name (Legal Business Name): GREGORY D LONGMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL 7TH FLOOR
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8125
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-1171
  • Fax: 314-362-3192
Mailing address:
  • Phone: 314-362-8808
  • Fax: 314-362-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number102740
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: