Provider Demographics
NPI:1477661809
Name:LONG, MARIE LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:LOUISE
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 1:8345 NW 66TH ST
Mailing Address - Street 2:#5896
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33166-2626
Mailing Address - Country:US
Mailing Address - Phone:503-949-4504
Mailing Address - Fax:
Practice Address - Street 1:6775 RED PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:OR
Practice Address - Zip Code:97378-9516
Practice Address - Country:US
Practice Address - Phone:503-949-4504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26287207T00000X
AZLT1654207T00000X
WY7604A207T00000X
IL207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG15871Medicare UPIN