Provider Demographics
NPI:1619955911
Name:LONG, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
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 1:1645 ROSTRAVER RD
Mailing Address - Street 2:
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-9655
Mailing Address - Country:US
Mailing Address - Phone:724-929-2640
Mailing Address - Fax:
Practice Address - Street 1:1645 ROSTRAVER RD
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-9655
Practice Address - Country:US
Practice Address - Phone:724-929-2640
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036822L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00683697Medicaid
PR769210Medicare ID - Type Unspecified
PA00683697Medicaid