Provider Demographics
NPI:1245448182
Name:LONG, STEVEN BRENISEN (MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:BRENISEN
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 1:4680 SPRING WOOD TRCE
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-1701
Mailing Address - Country:US
Mailing Address - Phone:678-622-1979
Mailing Address - Fax:
Practice Address - Street 1:9690 VENTANA WAY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-6394
Practice Address - Country:US
Practice Address - Phone:770-623-6773
Practice Address - Fax:770-232-9882
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049225208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice