=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558384214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY P LONG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 01/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 N HIGHWAY 47
-----------------------------------------------------
City | MARTHASVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-433-5411
-----------------------------------------------------
Fax | 636-433-2910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 PATIENTS FIRST DR
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63090-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-239-4100
-----------------------------------------------------
Fax | 636-390-4341
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | R9468
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------