Provider Demographics
NPI:1679685150
Name:LONG, MARY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:900 FAIRMONT RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-3847
Mailing Address - Country:US
Mailing Address - Phone:304-598-2233
Mailing Address - Fax:304-296-1792
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-598-6900
Practice Address - Fax:304-598-6914
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-09-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV21188207Q00000X, 193200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes193200000XGroupMulti-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000059Medicaid
WVI07371Medicare UPIN
WV3810000059Medicaid