Provider Demographics
NPI:1427182823
Name:LONGIE, KELLY BRENT (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BRENT
Last Name:LONGIE
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 1:727 KIRKWOOD MALL
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5753
Mailing Address - Country:US
Mailing Address - Phone:701-712-4500
Mailing Address - Fax:
Practice Address - Street 1:727 KIRKWOOD MALL
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5753
Practice Address - Country:US
Practice Address - Phone:701-712-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPT 10482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine