Provider Demographics
NPI:1770520330
Name:LONG, PHILLIP B (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:B
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5289
Mailing Address - Fax:740-446-5697
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5289
Practice Address - Fax:740-446-5697
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV184232085R0202X, 2085R0204X
OH35.0628922085R0204X
OH35-06-28922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0969797Medicaid
KY1770520330Medicaid
940000116OtherRR MEDICARE
OH0969797OtherMOLINA MEDICAID
000000006828OtherANTHEM BCBS
OH000000190752OtherUNISON MEDICAID
001714084OtherMOUNTAIN STATE BCBS
WV0120547000Medicaid
940000116OtherRR MEDICARE
KY1770520330Medicaid
WV0120547000Medicaid
WV0760286Medicare PIN