Healthcare Provider Details

I. General information

NPI: 1588292122
Provider Name (Legal Business Name): CODY MICHAEL LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SPRUCE ST
PHILADELPHIA PA
19107-6130
US

IV. Provider business mailing address

305 S 11TH ST APT 1R
PHILADELPHIA PA
19107-6094
US

V. Phone/Fax

Practice location:
  • Phone: 215-829-5410
  • Fax:
Mailing address:
  • Phone: 856-417-1859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: