Healthcare Provider Details

I. General information

NPI: 1437120615
Provider Name (Legal Business Name): MACK H LONGMIRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 11/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22890 VIRGIL GOODE HWY
BOONES MILL VA
24065
US

IV. Provider business mailing address

219 BARFOOT WEST RD
ROCKY MOUNT VA
24151-5322
US

V. Phone/Fax

Practice location:
  • Phone: 540-334-5511
  • Fax: 540-334-3174
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101-221204
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: