Healthcare Provider Details

I. General information

NPI: 1386058444
Provider Name (Legal Business Name): ADAM LONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 FEDERAL ST
CAMDEN NJ
08103-1539
US

IV. Provider business mailing address

106 BEECH ST
DOVER NJ
07801-2808
US

V. Phone/Fax

Practice location:
  • Phone: 856-583-2400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00348600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2253
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number25MD00348600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: