Provider Demographics
NPI:1417057902
Name:TIM LONG M.D., PSC
Entity Type:Organization
Organization Name:TIM LONG M.D., PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-746-5455
Mailing Address - Street 1:1320 ANDREA ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3334
Mailing Address - Country:US
Mailing Address - Phone:270-746-5455
Mailing Address - Fax:270-746-5688
Practice Address - Street 1:1320 ANDREA ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3334
Practice Address - Country:US
Practice Address - Phone:270-746-5455
Practice Address - Fax:270-746-5688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-24
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65936585Medicaid
DA8524OtherMEDICARE RAILROAD
000000216368OtherBC/BS
000000216368OtherBC/BS