MEDICARE: DR. DENNIS A. LONG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	3642582	IL

General Provider Information

NPI Number	:	1154454692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DENNIS A. LONG M.D.

Provider Business Mailing Address
First Line	:	2210 DEAN ST
Second Line	:	SUITE O-1
City	:	SAINT CHARLES
State	:	IL
Zip	:	60175-1066
Country	:	US
Telephone Number	:	630-377-7660
Fax Number	:

Provider Business Practice Location Address
First Line	:	2210 DEAN ST
Second Line	:	SUITE O-1
City	:	SAINT CHARLES
State	:	IL
Zip	:	60175-1066
Country	:	US
Telephone Number	:	630-377-7660
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	11/19/2007

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