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NPI Code Detail

MEDICARE: MR. CHARLES WILBURN LONG III PMHNP-BC

MEDICARE: MR. CHARLES WILBURN LONG III PMHNP-BC
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
1163W00000XRegistered Nurse1-141931AL
2363LP0808XPsychiatric/Mental Health Nurse Practitioner1-141931AL

General Provider Information

NPI Number : 1912599309
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. CHARLES WILBURN LONG III PMHNP-BC
Provider Business Mailing Address
First Line : 2501 INTERNATIONAL PARK DR
Second Line :
City : BIRMINGHAM
State : AL
Zip : 35243-4253
Country : US
Telephone Number : 205-813-7400
Fax Number :
Provider Business Practice Location Address
First Line : 2501 INTERNATIONAL PARK DR
Second Line :
City : BIRMINGHAM
State : AL
Zip : 35243-4253
Country : US
Telephone Number : 205-813-7400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/07/2021
Last Update Date : 09/27/2022

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