Healthcare Provider Details

I. General information

NPI: 1942490040
Provider Name (Legal Business Name): MATTHEW P LONGNECKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 TW ALEXANDER DR BLDG 101 ROOM A358
RESEARCH TRIANGLE PK NC
27709
US

IV. Provider business mailing address

PO BOX 12233 MD A3-05
DURHAM NC
27709-2233
US

V. Phone/Fax

Practice location:
  • Phone: 919-541-5118
  • Fax:
Mailing address:
  • Phone: 919-541-5118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number53277
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: