Provider Demographics
NPI:1790744241
Name:W. LAWRENCE LONG, PLLC
Entity Type:Organization
Organization Name:W. LAWRENCE LONG, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-885-1244
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-0042
Mailing Address - Country:US
Mailing Address - Phone:270-886-4556
Mailing Address - Fax:270-707-9650
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:CALDWELL COUNTY HOSPITAL
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-0410
Practice Address - Country:US
Practice Address - Phone:270-365-0442
Practice Address - Fax:270-365-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY182712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64182710Medicaid
KY000000185273OtherBLUE CROSS / BLUE SHIELD
KY64182710Medicaid
1859701Medicare PIN