Basic Information
| Provider Information | |||||||||
| NPI: | 1386072635 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONGNECK MEDICAL PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6642 LEWIS AVE # 12 | ||||||||
| Address2: | |||||||||
| City: | TEMPERANCE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481821201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342413891 | ||||||||
| FaxNumber: | 7342410014 | ||||||||
| Practice Location | |||||||||
| Address1: | 5623 E DUNBAR RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481619127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342413891 | ||||||||
| FaxNumber: | 7342410014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2013 | ||||||||
| LastUpdateDate: | 10/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | EISNER | ||||||||
| AuthorizedOfficialFirstName: | ARLYNNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7342413891 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M. D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301096175 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4301096175 | 01 | MI | STATE LICENSE NUMBER | OTHER |