Provider Demographics
NPI:1003052416
Name:THE LONGSTREET CLINIC, PC
Entity Type:Organization
Organization Name:THE LONGSTREET CLINIC, PC
Other - Org Name:THE LONGSTREET CLINIC DEPT OF PATHOLOGY/INTERLAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-718-1122
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE 260
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-535-0079
Practice Address - Fax:770-297-6610
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE LONGSTREET CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069-004291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000679764AMedicaid
GA000679764AMedicaid