Provider Demographics
NPI:1598797938
Name:LONG, EDWARD JR (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:LONG
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:24068 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-7600
Mailing Address - Country:US
Mailing Address - Phone:812-637-2323
Mailing Address - Fax:812-637-2878
Practice Address - Street 1:24068 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-7600
Practice Address - Country:US
Practice Address - Phone:812-637-2323
Practice Address - Fax:812-637-2878
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01034249A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND49568Medicare UPIN
OH0725071Medicare PIN