=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588720007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEWART MCLENDON LONG III MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2006
-----------------------------------------------------
Last Update Date | 08/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 W BROADWAY ST
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59802-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-329-5612
-----------------------------------------------------
Fax | 406-329-5606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12
-----------------------------------------------------
City | LIBERTY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99019-0012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-824-1284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 054274
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 2020-00263
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | MED-PHYS-LIC-11421
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------