Provider Demographics
NPI:1285663435
Name:EDWARD LONG JR MD
Entity Type:Organization
Organization Name:EDWARD LONG JR MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-637-2323
Mailing Address - Street 1:10925 MOCKERNUT DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030-1768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:812-637-2878
Practice Address - Street 1:24068 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-7600
Practice Address - Country:US
Practice Address - Phone:812-637-2323
Practice Address - Fax:812-637-2878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND49568Medicare UPIN
IN171800Medicare ID - Type Unspecified