Provider Demographics
NPI:1912241589
Name:LONG RIVER PHYSICIANS, LLC
Entity Type:Organization
Organization Name:LONG RIVER PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-401-2386
Mailing Address - Street 1:13737 NOEL RD
Mailing Address - Street 2:STE 1600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1331
Mailing Address - Country:US
Mailing Address - Phone:469-401-2386
Mailing Address - Fax:
Practice Address - Street 1:799 NEW HAVEN RD
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-4762
Practice Address - Country:US
Practice Address - Phone:203-723-5636
Practice Address - Fax:203-723-5634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty