Provider Demographics
NPI:1710204474
Name:MASON H LONG MD PA
Entity Type:Organization
Organization Name:MASON H LONG MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MASON
Authorized Official - Middle Name:H
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-824-6164
Mailing Address - Street 1:301 HEALTH PARK BLVD STE 325
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5771
Mailing Address - Country:US
Mailing Address - Phone:904-824-6164
Mailing Address - Fax:904-824-0365
Practice Address - Street 1:301 HEALTH PARK BLVD STE 325
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5771
Practice Address - Country:US
Practice Address - Phone:904-824-6164
Practice Address - Fax:904-824-0365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038939100Medicaid
FLE22623Medicare UPIN
FL08803Medicare PIN