Provider Demographics
NPI:1326039462
Name:LONG, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
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 1:4602 DEPT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0021
Mailing Address - Country:US
Mailing Address - Phone:906-225-3864
Mailing Address - Fax:906-225-3851
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:STE 36
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3864
Practice Address - Fax:906-225-3851
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080187364OtherRAILROAD MEDICARE
MI4416083Medicaid
MI080187364OtherRAILROAD MEDICARE
H66437Medicare UPIN