MEDICARE: RANDALL R LONG M.D.PHD

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	2084N0400X	Neurology Physician	45880	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265416119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL R LONG M.D.PHD

Provider Business Mailing Address
First Line	:	590 COURT ST
Second Line	:
City	:	KEENE
State	:	NH
Zip	:	03431-1719
Country	:	US
Telephone Number	:	603-354-5454
Fax Number	:

Provider Business Practice Location Address
First Line	:	590 COURT ST
Second Line	:
City	:	KEENE
State	:	NH
Zip	:	03431-1719
Country	:	US
Telephone Number	:	603-354-5454
Fax Number	:

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

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	06/04/2012

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