Basic Information
Provider Information | |||||||||
NPI: | 1093922882 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LONG | ||||||||
FirstName: | TIFFANY | ||||||||
MiddleName: | PINEDA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 MEMORIAL HOSPITAL DR | ||||||||
Address2: | SUITE200 | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366081786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514145900 | ||||||||
FaxNumber: | 2512811169 | ||||||||
Practice Location | |||||||||
Address1: | 101 MEMORIAL HOSPITAL DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366081786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514145900 | ||||||||
FaxNumber: | 2514598478 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2007 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | TD101093 | ME | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2084N0400X | 27839 | AL | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 29838 | 05 | AL |   | MEDICAID | FP011896 | 01 |   | DEA | OTHER | MD27839 | 01 | AL | ALABAMA CONTROLLED SUBSTANCE | OTHER | MD27839 | 01 | AL | MEDICAL LICENSE | OTHER |