Basic Information
Provider Information | |||||||||
NPI: | 1962482992 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LONG | ||||||||
FirstName: | GEORGANNE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 PARKWEST CIR | ||||||||
Address2: | SUITE 202 | ||||||||
City: | MIDLOTHIAN | ||||||||
State: | VA | ||||||||
PostalCode: | 231145551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8043202483 | ||||||||
FaxNumber: | 8047940050 | ||||||||
Practice Location | |||||||||
Address1: | 1401 JOHNSTON WILLIS DR | ||||||||
Address2: | SUITE 5000 | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232354730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8043202483 | ||||||||
FaxNumber: | 8047940050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2006 | ||||||||
LastUpdateDate: | 02/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 0101042241 | VA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
ID | Type | State | Issuer | Description | 2640631 | 01 |   | CIGNA | OTHER | 51812 | 01 |   | SENTARA | OTHER | 94537 | 01 |   | SOUTHERN HEALTH | OTHER | 328078 | 01 |   | MAMSI | OTHER | 0000083419002 | 01 |   | UNITED | OTHER | 0862248 | 01 |   | AETNAUSHEALTH | OTHER | 541941044002 | 01 |   | TRICARE | OTHER | 226117 | 01 |   | ANTHEM | OTHER | 51812 | 01 |   | OPTIMA HEALTH | OTHER | 11941 | 01 |   | CARENET | OTHER | 10240697 | 01 |   | VA PREMIER | OTHER |