Healthcare Provider Details

I. General information

NPI: 1396055299
Provider Name (Legal Business Name): RAYMOND A LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1397 BROAD AVE
GULFPORT MS
39501-2419
US

IV. Provider business mailing address

217 SAINT JOSEPH ST
WAVELAND MS
39576-4109
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-5012
  • Fax:
Mailing address:
  • Phone: 518-570-5910
  • Fax: 228-575-1964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMC-126
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number75914
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberMMD.94003.MD
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number29746
License Number StateMS
# 5
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberME80065
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: