Provider Demographics
NPI:1902883424
Name:LONG, EMMA L (MD)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PROVIDENT DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 PROVIDENT DR
Practice Address - Street 2:SUITE A
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3291
Practice Address - Country:US
Practice Address - Phone:574-372-7637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045980A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5887OtherPHYSICIANS HEALTH PLAN
IN000000241419OtherANTHEM
IN200141330Medicaid
5061595OtherAETNA
5061595OtherAETNA
IN070860KMedicare PIN
G49326Medicare UPIN
IN453220QMedicare PIN
080191196Medicare PIN