Provider Demographics
NPI:1578788014
Name:JAMES W LONG MD PC
Entity Type:Organization
Organization Name:JAMES W LONG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-581-7412
Mailing Address - Street 1:1020 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4141
Mailing Address - Country:US
Mailing Address - Phone:503-581-7412
Mailing Address - Fax:503-581-1095
Practice Address - Street 1:1020 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4141
Practice Address - Country:US
Practice Address - Phone:503-581-7412
Practice Address - Fax:503-581-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1604AT152W00000X
OR3152ATI152W00000X
ORMD10954207W00000X, 332H00000X
ORMD26362207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241802Medicaid
OR0550410001Medicare ID - Type UnspecifiedDME GROUP BILLING
R105114Medicare PIN
R0000WFBHVMedicare PIN
R00WFBHVAMedicare PIN
OR241802Medicaid
R137671Medicare PIN