Provider Demographics
NPI:1346535390
Name:LONG, KENNETH MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:LONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5907 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-6536
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:5907 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-6536
Practice Address - Country:US
Practice Address - Phone:228-769-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA311654207Q00000X
MS22826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01332510OtherRAILROAD MEDICARE
MS08224277Medicaid
MS08224277Medicaid