Provider Demographics
NPI:1619992799
Name:LONG, STEPHENIE R (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHENIE
Middle Name:R
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5645
Mailing Address - Country:US
Mailing Address - Phone:207-743-2544
Mailing Address - Fax:207-393-3132
Practice Address - Street 1:193 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5645
Practice Address - Country:US
Practice Address - Phone:207-743-2544
Practice Address - Fax:207-393-3132
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022299208600000X
MEMD25594208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1480517Medicaid
LAH50039Medicare UPIN
LA1480517Medicaid