1225088255 NPI number — CHARLES A CANNON JR MEMORIAL HOSPITAL INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225088255 NPI number — CHARLES A CANNON JR MEMORIAL HOSPITAL INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES A CANNON JR MEMORIAL HOSPITAL INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225088255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 FURMAN RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BOONE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28607-5049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-262-4111
Provider Business Mailing Address Fax Number:
828-262-4157

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
434 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28646-0787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-262-4133
Provider Business Practice Location Address Fax Number:
828-262-4103
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ETTA
Authorized Official Title or Position:
SR VP MEDICAL STAFF RELATIONS
Authorized Official Telephone Number:
828-262-4133

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NC0060X , with the licence number: H0037 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 152168200 . This is a "OWCP ACUTE CARE PROV NUMB" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0340005 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6065 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00103 . This is a "NC BLUE CROSS ACUTE CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5070877 . This is a "UNITED HEALTHCARE ACUTE #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3401323 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 290780 . This is a "MAMSI ACUTE CARE PROV NUM" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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