Provider Demographics
NPI:1689806432
Name:LONG, CORY R (MD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:R
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 1:1000 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-1948
Mailing Address - Country:US
Mailing Address - Phone:317-745-4451
Mailing Address - Fax:317-718-6740
Practice Address - Street 1:1000 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1948
Practice Address - Country:US
Practice Address - Phone:317-745-4451
Practice Address - Fax:317-718-6740
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01069779A207P00000X
OH097150207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000823438OtherANTHEM PIN
OH0076978Medicaid
IN201153410Medicaid
IN000000823438OtherANTHEM PIN
IN264430151Medicare PIN
H018531Medicare PIN