Provider Demographics
NPI:1063421071
Name:DELONG, BRIAN SCOTT (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:DELONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17003-1643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1251 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNVILLE
Practice Address - State:PA
Practice Address - Zip Code:17003
Practice Address - Country:US
Practice Address - Phone:717-988-0570
Practice Address - Fax:717-232-8152
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031602E174400000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001180754Medicaid