Provider Demographics
NPI:1831149707
Name:DRS. LONG AND VAUGHAN, P.A.
Entity type:Organization
Organization Name:DRS. LONG AND VAUGHAN, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:REID
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-295-2444
Mailing Address - Street 1:18 MEMORIAL MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4452
Mailing Address - Country:US
Mailing Address - Phone:864-295-2444
Mailing Address - Fax:
Practice Address - Street 1:18 MEMORIAL MEDICAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4452
Practice Address - Country:US
Practice Address - Phone:864-295-2444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10030208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA2924Medicaid
SCPA2924Medicaid