Provider Demographics
NPI:1275549180
Name:LONG, HEATHER (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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 1:225 PEAK RD
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-5454
Mailing Address - Country:US
Mailing Address - Phone:845-687-8960
Mailing Address - Fax:845-687-8960
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:@ ST. PETER'S HOSPITAL ER DEPT.
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-383-5450
Practice Address - Fax:518-328-3422
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213463-1207P00000X, 207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02433489Medicaid
NY02433489Medicaid
NYH77237Medicare UPIN