Provider Demographics
NPI:1104844406
Name:LONG, TERESA CHARL (MD, MPH)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:CHARL
Last Name:LONG
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 PARSONS AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5331
Mailing Address - Country:US
Mailing Address - Phone:614-645-7417
Mailing Address - Fax:
Practice Address - Street 1:240 PARSONS AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5331
Practice Address - Country:US
Practice Address - Phone:614-645-7417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0540742083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2439730Medicaid
OH316400223035OtherCARESOURCE CLINIC #
OHF68922Medicare UPIN
OHL04121801Medicare ID - Type UnspecifiedMEDICARE #