Healthcare Provider Details

I. General information

NPI: 1417933870
Provider Name (Legal Business Name): KEITH C LONG M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13737 SPOTSWOOD TRL
ELKTON VA
22827-3200
US

IV. Provider business mailing address

PO BOX 1430
HARRISONBURG VA
22803-1430
US

V. Phone/Fax

Practice location:
  • Phone: 540-713-4100
  • Fax: 844-305-8671
Mailing address:
  • Phone: 540-713-4100
  • Fax: 844-305-8671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101054658
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: