MEDICARE: JOHN EARL LONG MD

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	207P00000X	Emergency Medicine Physician	ME 63156	FL

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

General Provider Information

NPI Number	:	1629284369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN EARL LONG MD

Provider Business Mailing Address
First Line	:	13690 LONGS LANDING RD W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-5423
Country	:	US
Telephone Number	:	904-535-7801
Fax Number	:	904-221-7751

Provider Business Practice Location Address
First Line	:	13690 LONGS LANDING RD W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-5423
Country	:	US
Telephone Number	:	904-535-7801
Fax Number	:	904-221-7751

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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