Provider Demographics
NPI:1427050368
Name:LONG, THAD D (MD)
Entity type:Individual
Prefix:
First Name:THAD
Middle Name:D
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1601 FAIR RD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1698
Mailing Address - Country:US
Mailing Address - Phone:678-469-0007
Mailing Address - Fax:321-206-0834
Practice Address - Street 1:1601 FAIR RD
Practice Address - Street 2:SUITE 1100
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1698
Practice Address - Country:US
Practice Address - Phone:678-469-0007
Practice Address - Fax:321-206-0834
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2012-08-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0207692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00237157HMedicaid
GA00237157HMedicaid