Provider Demographics
NPI:1083608764
Name:LONG, LIBBY A (MD)
Entity Type:Individual
Prefix:DR
First Name:LIBBY
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LIBBY
Other - Middle Name:A
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1370 GATEWAY BLVD.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129
Mailing Address - Country:US
Mailing Address - Phone:615-890-0641
Mailing Address - Fax:615-890-0193
Practice Address - Street 1:1370 GATEWAY BLVD.
Practice Address - Street 2:SUITE 110
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129
Practice Address - Country:US
Practice Address - Phone:615-890-9008
Practice Address - Fax:615-890-0193
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112878208000000X
TNMD0000041089208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440829Medicaid
IL036112878Medicaid
TN5440829Medicaid