Basic Information
| Provider Information | |||||||||
| NPI: | 1801890686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | HERBERT | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307818 | ||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 RIVER DR | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403361272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067230399 | ||||||||
| FaxNumber: | 6067230379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31482 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 61-1341297 | 01 | KY | TRICARE | OTHER | 5211107 | 01 | KY | AETNA ID | OTHER | 000889063 | 01 | KY | HUMANA | OTHER | 64314826 | 05 | KY | MEDICAID | 000000052184 | 01 | KY | ANTHEM BCBS ID | OTHER | 01-00767 | 01 | KY | UNITED HEATLH CARE | OTHER | 1166070 | 01 | KY | CHA HEALTH | OTHER | 2768 | 01 | KY | BLUEGRASS FAMILY HEALTH | OTHER | 35001262 | 05 | KY | MEDICAID | 1532269 | 01 | KY | UMWA | OTHER |