Healthcare Provider Details

I. General information

NPI: 1962482992
Provider Name (Legal Business Name): GEORGANNE LONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 JOHNSTON WILLIS DR SUITE 5000
RICHMOND VA
23235-4730
US

IV. Provider business mailing address

1 PARKWEST CIR SUITE 202
MIDLOTHIAN VA
23114-5551
US

V. Phone/Fax

Practice location:
  • Phone: 804-320-2483
  • Fax: 804-794-0050
Mailing address:
  • Phone: 804-320-2483
  • Fax: 804-794-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number0101042241
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: