Provider Demographics
NPI:1003973272
Name:LONG, RANDI J (MD)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:J
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:J
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33717 WOODWARD AVE STE 416
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-0913
Mailing Address - Country:US
Mailing Address - Phone:248-809-1227
Mailing Address - Fax:248-809-1228
Practice Address - Street 1:3601 W 13 MILE ROAD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-809-1227
Practice Address - Fax:248-809-1228
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056088208100000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3480240Medicaid
MIG76713Medicare UPIN
MI0M67010Medicare ID - Type Unspecified