Provider Demographics
NPI:1275567612
Name:LONG, DALE E (DO)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:E
Last Name:LONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1165
Mailing Address - Country:US
Mailing Address - Phone:618-624-3368
Mailing Address - Fax:618-624-3387
Practice Address - Street 1:103 N OAK ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1165
Practice Address - Country:US
Practice Address - Phone:618-624-3368
Practice Address - Fax:618-624-3387
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-094722207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C78281Medicare UPIN