Healthcare Provider Details

I. General information

NPI: 1649268822
Provider Name (Legal Business Name): BILLY W LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 N STATE ST SUITE 203
JACKSON MS
39202-1658
US

IV. Provider business mailing address

1421 N STATE ST SUITE 203
JACKSON MS
39202-1658
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-1234
  • Fax: 601-354-3881
Mailing address:
  • Phone: 601-355-1234
  • Fax: 601-354-3881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number06744
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: