Healthcare Provider Details

I. General information

NPI: 1831149707
Provider Name (Legal Business Name): DRS. LONG AND VAUGHAN, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 MEMORIAL MEDICAL DR
GREENVILLE SC
29605-4452
US

IV. Provider business mailing address

18 MEMORIAL MEDICAL DR
GREENVILLE SC
29605-4452
US

V. Phone/Fax

Practice location:
  • Phone: 864-295-2444
  • Fax:
Mailing address:
  • Phone: 864-295-2444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number10030
License Number StateSC

VIII. Authorized Official

Name: DR. DONALD REID VAUGHAN
Title or Position: CORPORATE PRESIDENT
Credential: M.D.
Phone: 864-295-2444