Healthcare Provider Details

I. General information

NPI: 1326176223
Provider Name (Legal Business Name): KEVIN BRUCE LONGIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 KIRKWOOD MALL
BISMARCK ND
58504-5753
US

IV. Provider business mailing address

727 KIRKWOOD MALL
BISMARCK ND
58504-5753
US

V. Phone/Fax

Practice location:
  • Phone: 701-712-4500
  • Fax: 701-530-6469
Mailing address:
  • Phone: 701-712-4500
  • Fax: 701-530-6469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10483
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: