Provider Demographics
NPI:1780900274
Name:LONG, ELIZABETH BROMAN (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:BROMAN
Last Name:LONG
Suffix:
Gender:F
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:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:GA
Mailing Address - Zip Code:30628-0459
Mailing Address - Country:US
Mailing Address - Phone:706-788-3234
Mailing Address - Fax:706-788-2936
Practice Address - Street 1:11 CHARLIE MORRIS RD
Practice Address - Street 2:
Practice Address - City:COLBERT
Practice Address - State:GA
Practice Address - Zip Code:30628-2445
Practice Address - Country:US
Practice Address - Phone:706-788-2127
Practice Address - Fax:706-788-2815
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069308208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134590AMedicaid