Provider Demographics
NPI:1396055299
Name:LONG, RAYMOND A (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:A
Last Name:LONG
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 1:217 SAINT JOSEPH ST
Mailing Address - Street 2:
Mailing Address - City:WAVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39576-4109
Mailing Address - Country:US
Mailing Address - Phone:518-570-5910
Mailing Address - Fax:228-575-1964
Practice Address - Street 1:1397 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2419
Practice Address - Country:US
Practice Address - Phone:228-867-5012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUMC-126207X00000X
GA75914207XX0801X
SCMMD.94003.MD207XX0801X
MS29746207XX0801X
FLME80065207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FL14J8YOtherBC/BS
FLPENDINGMedicaid
FL7684539OtherAETNA
FLE4118YMedicare PIN