Provider Demographics
NPI:1700018843
Name:BRIAN K LONG MD, PLLC
Entity Type:Organization
Organization Name:BRIAN K LONG MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-872-2350
Mailing Address - Street 1:211 S CENTER ST
Mailing Address - Street 2:SUITE 217A
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-5873
Mailing Address - Country:US
Mailing Address - Phone:704-872-2350
Mailing Address - Fax:704-872-2351
Practice Address - Street 1:211 S CENTER ST
Practice Address - Street 2:SUITE 217A
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5873
Practice Address - Country:US
Practice Address - Phone:704-872-2350
Practice Address - Fax:704-872-2351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500391103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901922Medicaid