Provider Demographics
NPI:1881817286
Name:LONGE, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:LONGE
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:PO BOX 3845
Mailing Address - Street 2:1125 TROUPE STREET
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3845
Mailing Address - Country:US
Mailing Address - Phone:706-737-4275
Mailing Address - Fax:706-731-5289
Practice Address - Street 1:4350 TOWNE CENTRE DR
Practice Address - Street 2:SUITE 1000
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3301
Practice Address - Country:US
Practice Address - Phone:706-868-3940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0582732085B0100X, 2085R0202X, 2085U0001X, 2085D0003X, 2085N0700X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG58273Medicaid
GA392555936 A-KMedicaid
GA511I300193Medicare PIN