Provider Demographics
NPI:1801978911
Name:LONG, JOSEPH MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:7000 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4313
Practice Address - Country:US
Practice Address - Phone:505-344-9478
Practice Address - Fax:505-344-2783
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2018-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033377A207Q00000X
ININ01033377208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000897901OtherBCBS BMG IRELAND RD
IN000000795486OtherBCBS BMG ORTHOPEDIC TRAUMA
IN100223880Medicaid
IN100223880AMedicaid
INP01173108OtherRR MEDICARE
INP01173108OtherRR MEDICARE
IN000000795486OtherBCBS BMG ORTHOPEDIC TRAUMA
E05813Medicare UPIN