Provider Demographics
NPI:1033194337
Name:LONG, RONALD J (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:J
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 1:500 PLAZA CIRCLE
Mailing Address - Street 2:SUITE J
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325
Mailing Address - Country:US
Mailing Address - Phone:864-833-3400
Mailing Address - Fax:864-833-9039
Practice Address - Street 1:1306 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440
Practice Address - Country:US
Practice Address - Phone:843-546-3132
Practice Address - Fax:843-546-2268
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12662207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC126624Medicaid