Provider Demographics
NPI:1417933870
Name:LONG, KEITH C (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:C
Last Name:LONG
Suffix:
Gender:M
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:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22803-1430
Mailing Address - Country:US
Mailing Address - Phone:540-713-4100
Mailing Address - Fax:844-305-8671
Practice Address - Street 1:13737 SPOTSWOOD TRL
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:VA
Practice Address - Zip Code:22827-3200
Practice Address - Country:US
Practice Address - Phone:540-713-4100
Practice Address - Fax:844-305-8671
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054658207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1417933870Medicaid
VA1417933870Medicaid