Provider Demographics
NPI:1609814391
Name:LONG, KYLE Y (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:Y
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1305 S CANNON BLVD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6232
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:
Practice Address - Street 1:725 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4206
Practice Address - Country:US
Practice Address - Phone:336-607-8523
Practice Address - Fax:336-748-5438
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004003732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137NWMedicaid
NCI16282Medicare UPIN
NC89137NWMedicaid