Provider Demographics
NPI:1033475652
Name:LONG, ERIC MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MARTIN
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:400 HIGHLAND AVE.
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044
Practice Address - Country:US
Practice Address - Phone:717-242-7473
Practice Address - Fax:717-242-7478
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD456900207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program