Provider Demographics
NPI:1699743567
Name:LONG, TIMOTHY R (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:LONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CHESTNUT HILL CT
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7002
Mailing Address - Country:US
Mailing Address - Phone:270-746-5455
Mailing Address - Fax:270-746-5688
Practice Address - Street 1:1320 ANDREA ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3334
Practice Address - Country:US
Practice Address - Phone:270-746-5455
Practice Address - Fax:270-746-5688
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY33989207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000216368OtherANTHEM BLUE CROSS & BLUE
KY35L1OtherANTHEM BC/BS
KY64339898Medicaid
000000216368OtherANTHEM BLUE CROSS & BLUE
KY35L1OtherANTHEM BC/BS
G87048Medicare UPIN