Provider Demographics
NPI:1619998283
Name:LONG, SUSAN E (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
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 1:1 AMALIA DR
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2239
Mailing Address - Country:US
Mailing Address - Phone:304-473-2000
Mailing Address - Fax:304-473-2180
Practice Address - Street 1:1 AMALIA DR
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2239
Practice Address - Country:US
Practice Address - Phone:304-473-2000
Practice Address - Fax:304-473-2180
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18992208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0126735000Medicaid
LO7361451Medicare PIN
WVG50170Medicare UPIN