Provider Demographics
NPI:1174889174
Name:LONG, RACHEL (D O)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14611-3201
Mailing Address - Country:US
Mailing Address - Phone:585-368-3720
Mailing Address - Fax:585-368-3723
Practice Address - Street 1:89 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-3201
Practice Address - Country:US
Practice Address - Phone:585-368-3720
Practice Address - Fax:585-368-3723
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280922207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04242971Medicaid
NY04242971Medicaid
NYJ400243689-GRPBA0017Medicare PIN