Basic Information
| Provider Information | |||||||||
| NPI: | 1639383532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | DEPT OF INTERNAL MEDICINE/DIVISION OF CARDIOLOGY | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 06/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | E09167 | MS | N | Pharmacy Service Providers | Pharmacist | 207R00000X | 19752 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 19752 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | 19752 | MS | Y |
ID Information
| ID | Type | State | Issuer | Description | P01330224 | 01 | MS | RAILROAD MEDICARE PTAN | OTHER | 2406639 | 05 | LA | MEDICAID | 133721 | 05 | AL | MEDICAID | 00121925 | 05 | MS | MEDICAID |