Provider Demographics
NPI:1073678520
Name:INTERNAL MEDICINE OF LONG BEACH PLLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE OF LONG BEACH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRIS
Authorized Official - Middle Name:B
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-575-4374
Mailing Address - Street 1:2 TOWER PLZ
Mailing Address - Street 2:PINEVILLE ROAD SUITE E
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-3900
Mailing Address - Country:US
Mailing Address - Phone:228-575-4374
Mailing Address - Fax:228-575-4303
Practice Address - Street 1:2 TOWER PLZ
Practice Address - Street 2:PINEVILLE ROAD SUITE E
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-3900
Practice Address - Country:US
Practice Address - Phone:228-575-4374
Practice Address - Fax:228-575-4303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15183207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08603563Medicaid
MS08603563Medicaid