Provider Demographics
NPI:1265416119
Name:LONG, RANDALL R (MDPHD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:R
Last Name:LONG
Suffix:
Gender:M
Credentials:MDPHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 COURT ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-1719
Mailing Address - Country:US
Mailing Address - Phone:603-354-5454
Mailing Address - Fax:
Practice Address - Street 1:590 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1719
Practice Address - Country:US
Practice Address - Phone:603-354-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA458802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0109185Medicaid
NH30208176Medicaid
NHN0187602Medicare PIN
MAB76989Medicare UPIN