Provider Demographics
NPI:1548247430
Name:LONG, RUSSELL E (CRNA)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:LONG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37371-0220
Mailing Address - Country:US
Mailing Address - Phone:423-424-3695
Mailing Address - Fax:
Practice Address - Street 1:1114 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4150
Practice Address - Country:US
Practice Address - Phone:423-745-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNCRNA#10632367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4129533OtherBLUE CROSS BLUE SHIELD
TN3629553Medicaid
TNP00343315OtherRR MEDICARE
TN3629553Medicare PIN