Healthcare Provider Details

I. General information

NPI: 1255780680
Provider Name (Legal Business Name): BEN G LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 ALCORN DR
CORINTH MS
38834-9388
US

IV. Provider business mailing address

1144 PEACHTREE ST
CORINTH MS
38834-2327
US

V. Phone/Fax

Practice location:
  • Phone: 662-293-1000
  • Fax:
Mailing address:
  • Phone: 662-284-5056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLL39688
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: