Healthcare Provider Details

I. General information

NPI: 1457683385
Provider Name (Legal Business Name): MILLY H LONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 E CHESTER PIKE
RIDLEY PARK PA
19078-2212
US

IV. Provider business mailing address

1350 EDGMONT AVE STE 1500
CHESTER PA
19013-3962
US

V. Phone/Fax

Practice location:
  • Phone: 610-595-6586
  • Fax: 610-595-6787
Mailing address:
  • Phone: 610-595-6586
  • Fax: 610-595-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD040300L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: