Provider Demographics
NPI:1023019759
Name:LONG, TROY DEAN (MD)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:DEAN
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 CAMPUS DRIVE #10
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441
Mailing Address - Country:US
Mailing Address - Phone:763-559-2171
Mailing Address - Fax:763-694-9000
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2926
Practice Address - Country:US
Practice Address - Phone:763-559-2171
Practice Address - Fax:763-694-9000
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1018662085R0202X, 2085R0204X, 2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
I15893Medicare UPIN