Healthcare Provider Details

I. General information

NPI: 1750518213
Provider Name (Legal Business Name): MICAH LONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE UW HOSPITALS - DEPARTMENT OF ANESTHESIOLOGY
MADISON WI
53792-0001
US

IV. Provider business mailing address

600 HIGHLAND AVE UW HOSPITALS - DEPARTMENT OF ANESTHESIOLOGY
MADISON WI
53792-0001
US

V. Phone/Fax

Practice location:
  • Phone: 920-716-5410
  • Fax:
Mailing address:
  • Phone: 920-716-5410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number60758-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: