Provider Demographics
NPI:1326019977
Name:THE LONGSTREET CLINIC, PC
Entity type:Organization
Organization Name:THE LONGSTREET CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:LOWE
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-718-1122
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-718-1122
Practice Address - Fax:770-533-4786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
207RH0003X, 207V00000X, 207VG0400X, 207VM0101X, 207X00000X, 207ZP0102X, 208000000X, 2080N0001X, 208100000X, 208600000X, 208D00000X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000679764AMedicaid
GA4541000001Medicare PIN
GA000679764AMedicaid
GRP 2440Medicare ID - Type Unspecified