Provider Demographics
NPI:1720062656
Name:LONG, RICHARD H (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:H
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 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 HARRISON AVE
Practice Address - Street 2:YACC 4
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4001
Practice Address - Country:US
Practice Address - Phone:617-414-2080
Practice Address - Fax:617-414-2090
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD07395207Q00000X
MA71219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110047111AMedicaid
RI7001685Medicaid
MAJ0864001Medicare PIN
RIE12406Medicare UPIN
RI7001685Medicaid
RI089025332Medicare ID - Type UnspecifiedMEDICARE
MASX4907Medicare PIN