Provider Demographics
NPI:1003870650
Name:LONG, ROBERT DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DALE
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837
Mailing Address - Country:US
Mailing Address - Phone:570-523-1109
Mailing Address - Fax:570-523-7736
Practice Address - Street 1:3 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837
Practice Address - Country:US
Practice Address - Phone:570-523-1109
Practice Address - Fax:570-523-7736
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2010-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD016589E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
02500700OtherBLUE CROSS
LO70425OtherBLUE SHIELD
LO70425OtherBLUE SHIELD
C28931Medicare UPIN