Provider Demographics
NPI:1043215403
Name:LONG, KATHLEEN A (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:531 ROSELANE ST NW STE 710
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6975
Mailing Address - Country:US
Mailing Address - Phone:678-331-3297
Mailing Address - Fax:678-581-7187
Practice Address - Street 1:144 BILL CARRUTH PKWY STE 3100
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3819
Practice Address - Country:US
Practice Address - Phone:678-363-1940
Practice Address - Fax:678-581-7110
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2019-04-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA038549207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00599981FMedicaid
GA000599981AEMedicaid
GA000599981ADMedicaid
GA1043215403OtherNPI NUMBER
GA00599981ABMedicaid
GA00599981GMedicaid
GA00599981DMedicaid
AL009932125Medicaid
GA0741780009OtherSUPPLIER NPI NUMBER (CANTON)
GA1801924857OtherSUPPLIER NPI NUMBER (JASPER)
GA00599981DMedicaid
GA00599981ABMedicaid
GA000599981AEMedicaid