Provider Demographics
NPI:1194739623
Name:LONG, ALYS L (DO)
Entity type:Individual
Prefix:DR
First Name:ALYS
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 HAMILTON RD STE 102E
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1941
Mailing Address - Country:US
Mailing Address - Phone:517-482-2118
Mailing Address - Fax:
Practice Address - Street 1:2900 COLLINS RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8394
Practice Address - Country:US
Practice Address - Phone:517-482-2118
Practice Address - Fax:517-484-0291
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017171207L00000X
MI5601003222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN34260004Medicare ID - Type Unspecified
MIN88100018Medicare PIN
MIC37626057Medicare PIN