Provider Demographics
NPI:1184045692
Name:LONG, MICHAEL I
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LONG
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 OHARA PL
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-1248
Mailing Address - Country:US
Mailing Address - Phone:631-428-0649
Mailing Address - Fax:
Practice Address - Street 1:11 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3739
Practice Address - Country:US
Practice Address - Phone:631-920-8306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276687163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse