Provider Demographics
NPI:1477618551
Name:LONG, HEIDI JILL (MD)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:JILL
Last Name:LONG
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 JOHNSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1605
Mailing Address - Country:US
Mailing Address - Phone:518-572-2215
Mailing Address - Fax:
Practice Address - Street 1:1001 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1605
Practice Address - Country:US
Practice Address - Phone:518-572-2215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223912-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02743295Medicaid