Provider Demographics
NPI:1558554808
Name:LONG, ANDREW JAMES (DO)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMES
Last Name:LONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:419 S CORAL ST
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-2503
Mailing Address - Country:US
Mailing Address - Phone:231-258-7777
Mailing Address - Fax:231-935-8099
Practice Address - Street 1:419 S CORAL ST
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-2503
Practice Address - Country:US
Practice Address - Phone:231-258-7777
Practice Address - Fax:231-935-8099
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101016386207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1558554808Medicaid
MI0Z56005018Medicare PIN