Basic Information
Provider Information | |||||||||
NPI: | 1346229002 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LONG | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 249 | ||||||||
Address2: |   | ||||||||
City: | CONOVER | ||||||||
State: | NC | ||||||||
PostalCode: | 286130249 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8284659730 | ||||||||
FaxNumber: | 8284659293 | ||||||||
Practice Location | |||||||||
Address1: | 305 1ST ST E | ||||||||
Address2: |   | ||||||||
City: | CONOVER | ||||||||
State: | NC | ||||||||
PostalCode: | 286131715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8284643821 | ||||||||
FaxNumber: | 8284648994 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2006 | ||||||||
LastUpdateDate: | 02/25/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 18019 | NC | N |   | Other Service Providers | Legal Medicine |   | 207Q00000X | 7218019 | NC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | CN8132 | 01 | NC | MEDICARE RAILROAD | OTHER | 8952800 | 05 | NC |   | MEDICAID | AL5520235 | 01 | NC | DEA | OTHER |