Provider Demographics
NPI:1386072635
Name:LONGNECK MEDICAL PLLC
Entity type:Organization
Organization Name:LONGNECK MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARLYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:EISNER
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:734-241-3891
Mailing Address - Street 1:6642 LEWIS AVE # 12
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-1201
Mailing Address - Country:US
Mailing Address - Phone:734-241-3891
Mailing Address - Fax:734-241-0014
Practice Address - Street 1:5623 E DUNBAR RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-9127
Practice Address - Country:US
Practice Address - Phone:734-241-3891
Practice Address - Fax:734-241-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096175207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301096175OtherSTATE LICENSE NUMBER