Provider Demographics
NPI:1538772868
Name:LONGMIRE HEALTH GROUP
Entity type:Organization
Organization Name:LONGMIRE HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:LONGMIRE
Authorized Official - Suffix:II
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:901-833-7095
Mailing Address - Street 1:9160 HIGHWAY 64 STE 12-219
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-4766
Mailing Address - Country:US
Mailing Address - Phone:901-833-7095
Mailing Address - Fax:
Practice Address - Street 1:1331 UNION AVE STE 1024
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7509
Practice Address - Country:US
Practice Address - Phone:901-833-7095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ033644Medicaid