Provider Demographics
NPI:1134108640
Name:LONG, PRISCILLA E (MD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:E
Last Name:LONG
Suffix:
Gender:F
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 MEDICAL DR
Mailing Address - Street 2:P.O. BOX 311
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6877
Mailing Address - Country:US
Mailing Address - Phone:573-231-3116
Mailing Address - Fax:573-231-3714
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6877
Practice Address - Country:US
Practice Address - Phone:573-231-3116
Practice Address - Fax:573-231-3714
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4H55207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202501516Medicaid
MO028013772Medicare ID - Type Unspecified
A13226Medicare UPIN