Basic Information
| Provider Information | |||||||||
| NPI: | 1457457764 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 N RIVERSIDE RD | ||||||||
| Address2: | SUITE G 50 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645072553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166714888 | ||||||||
| FaxNumber: | 8166714890 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 N RIVERSIDE RD | ||||||||
| Address2: | SUITE G 50 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645072553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162716666 | ||||||||
| FaxNumber: | 8162711300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 11/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | R5N29 | MO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100119400B | 05 | KS | MEDICAID | 202888509 | 05 | MO | MEDICAID | 020054316 | 01 | MO | RR MEDICARE | OTHER |