Healthcare Provider Details

I. General information

NPI: 1972586816
Provider Name (Legal Business Name): RICHARD WILLIAM LONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E 2ND ST
ERIE PA
16507-1537
US

IV. Provider business mailing address

120 E 2ND ST
ERIE PA
16507-1537
US

V. Phone/Fax

Practice location:
  • Phone: 814-453-6751
  • Fax: 814-454-0925
Mailing address:
  • Phone: 814-453-6751
  • Fax: 814-454-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD041795E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: