Healthcare Provider Details

I. General information

NPI: 1275549180
Provider Name (Legal Business Name): HEATHER LONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S MANNING BLVD @ ST. PETER'S HOSPITAL ER DEPT.
ALBANY NY
12208-1707
US

IV. Provider business mailing address

225 PEAK RD
STONE RIDGE NY
12484-5454
US

V. Phone/Fax

Practice location:
  • Phone: 518-383-5450
  • Fax: 518-328-3422
Mailing address:
  • Phone: 845-687-8960
  • Fax: 845-687-8960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number213463-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number213463-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: