Basic Information
| Provider Information | |||||||||
| NPI: | 1033194337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 PLAZA CIRCLE | ||||||||
| Address2: | SUITE J | ||||||||
| City: | CLINTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648333400 | ||||||||
| FaxNumber: | 8648339039 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 N FRASER ST | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435463132 | ||||||||
| FaxNumber: | 8435462268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 12662 | SC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 126624 | 05 | SC | MEDICAID |