Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 19752 | MS |
N | 111NI0900X | Internist | 19752 | MS |
Y | 207RA0001X | Advanced Heart Failure and Transplant Cardiologist | 19752 | MS |
N | 207RC0000X | Internist - Cardiovascular Disease | 19752 | MS |
NPI | 1639383532 |
---|---|
Provider Name | Dr. Robert Craig Long |
First Address | Jackson, MS 39216-4500 |
Second Address | Jackson, MS 39216-4500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2007 |
Last Update Date | 06/06/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00121925 | (05) | MS |
133721 | (05) | AL |
2406639 | (05) | LA |
P01330224 | RAILROAD MEDICARE PTAN (01) | MS |