Provider Demographics
NPI:1770705873
Name:HERBERT W LONG
Entity type:Organization
Organization Name:HERBERT W LONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYISICAN
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-723-0399
Mailing Address - Street 1:417 RIVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336
Mailing Address - Country:US
Mailing Address - Phone:606-723-0399
Mailing Address - Fax:606-723-0379
Practice Address - Street 1:417 RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336
Practice Address - Country:US
Practice Address - Phone:606-723-0399
Practice Address - Fax:606-723-0379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31482261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY35001262Medicaid
KY31482OtherLICENSE
KY31482OtherLICENSE
KYG70336Medicare UPIN