Basic Information
Provider Information | |||||||||
NPI: | 1912241589 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LONG RIVER PHYSICIANS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13737 NOEL RD | ||||||||
Address2: | STE 1600 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752401331 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4694012386 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 799 NEW HAVEN RD | ||||||||
Address2: |   | ||||||||
City: | NAUGATUCK | ||||||||
State: | CT | ||||||||
PostalCode: | 067704762 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037235636 | ||||||||
FaxNumber: | 2037235634 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2012 | ||||||||
LastUpdateDate: | 12/24/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | RUSSELL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4694012386 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.