Provider Demographics
NPI:1972869493
Name:LONG, REUEL SHANNON (MD)
Entity type:Individual
Prefix:DR
First Name:REUEL
Middle Name:SHANNON
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 1:6363 JENNINGS RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9642
Mailing Address - Country:US
Mailing Address - Phone:734-665-3070
Mailing Address - Fax:
Practice Address - Street 1:6363 JENNINGS RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9642
Practice Address - Country:US
Practice Address - Phone:734-665-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI028643208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice