Provider Demographics
NPI:1639283807
Name:STEPHENIE R. LONG, MD LLC
Entity Type:Organization
Organization Name:STEPHENIE R. LONG, MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHENIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-281-0065
Mailing Address - Street 1:420 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-4514
Mailing Address - Country:US
Mailing Address - Phone:318-281-0065
Mailing Address - Fax:318-281-0052
Practice Address - Street 1:420 S VINE ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4514
Practice Address - Country:US
Practice Address - Phone:318-281-0065
Practice Address - Fax:318-281-0052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022299208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH50039Medicare UPIN