Provider Demographics
NPI:1033548052
Name:WATAUGA MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WATAUGA MEDICAL CENTER, INC.
Other - Org Name:APPALACHIAN REGIONAL PAIN MANAGEMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP MEDICAL STAFF RELATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ETTA
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA-CPMSM
Authorized Official - Phone:828-262-4133
Mailing Address - Street 1:336 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5008
Mailing Address - Country:US
Mailing Address - Phone:828-262-4103
Mailing Address - Fax:828-262-4103
Practice Address - Street 1:336 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5008
Practice Address - Country:US
Practice Address - Phone:828-265-5493
Practice Address - Fax:828-266-1176
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APPALACHIAN REGIONAL HEALTH CARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0077261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA509Medicare PIN