Provider Demographics
NPI:1295025716
Name:LONG, RACHAEL OLIVIA
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:OLIVIA
Last Name:LONG
Suffix:
Gender:F
Credentials:
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Mailing Address - Street 1:6600 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-4744
Mailing Address - Country:US
Mailing Address - Phone:952-993-7711
Mailing Address - Fax:952-993-6798
Practice Address - Street 1:9300 NOBLE PKWY N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-5500
Practice Address - Country:US
Practice Address - Phone:763-236-5300
Practice Address - Fax:763-236-5250
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2020-11-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN55362207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400177720Medicare PIN