Provider Demographics
NPI:1104127703
Name:TONI L LONG M D A MEDICAL CORPORATION
Entity type:Organization
Organization Name:TONI L LONG M D A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-915-9154
Mailing Address - Street 1:2020 SANTA MONICA BLVD STE 570
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2131
Mailing Address - Country:US
Mailing Address - Phone:310-453-9289
Mailing Address - Fax:310-453-2161
Practice Address - Street 1:2020 SANTA MONICA BLVD STE 570
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2131
Practice Address - Country:US
Practice Address - Phone:310-453-9289
Practice Address - Fax:310-453-2161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65155207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG65155Medicare UPIN