Provider Demographics
NPI:1265487482
Name:LONGLEY, MICHAEL B (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:LONGLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12479 TELECOM DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0913
Mailing Address - Country:US
Mailing Address - Phone:813-972-4199
Mailing Address - Fax:813-972-5753
Practice Address - Street 1:2600 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-9207
Practice Address - Country:US
Practice Address - Phone:813-929-5000
Practice Address - Fax:813-972-5753
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94125207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL29386OtherBCBS OF FLORIDA
FL274028100Medicaid
FL29386OtherBCBS OF FLORIDA
I41996Medicare UPIN
FL29386WMedicare PIN
FL29386YMedicare PIN
FLP00292459Medicare PIN
P00607592Medicare PIN
FL29386XMedicare PIN