Provider Demographics
NPI:1558384214
Name:LONG, TIMOTHY P (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:P
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 1:901 PATIENTS FIRST DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4700
Mailing Address - Country:US
Mailing Address - Phone:636-239-4100
Mailing Address - Fax:636-390-4341
Practice Address - Street 1:200 N HIGHWAY 47
Practice Address - Street 2:
Practice Address - City:MARTHASVILLE
Practice Address - State:MO
Practice Address - Zip Code:63357
Practice Address - Country:US
Practice Address - Phone:636-433-5411
Practice Address - Fax:636-433-2910
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010121863OtherRAILROAD MEDICARE
MO200987253Medicaid
006012943Medicare PIN
006012943Medicare ID - Type Unspecified
MO200987253Medicaid