Provider Demographics
NPI:1053510081
Name:CHARLES A CANNON JR MEMORIAL HOSPITAL INC.
Entity Type:Organization
Organization Name:CHARLES A CANNON JR MEMORIAL HOSPITAL INC.
Other - Org Name:CANNON MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:STHAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-737-7865
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:LINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28646-0459
Mailing Address - Country:US
Mailing Address - Phone:828-737-7865
Mailing Address - Fax:828-737-7867
Practice Address - Street 1:436 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:LINVILLE
Practice Address - State:NC
Practice Address - Zip Code:28646
Practice Address - Country:US
Practice Address - Phone:828-737-7865
Practice Address - Fax:828-737-7867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20060073261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC132NKOtherBCBS PROVIDER NUMBER
NC5902144MedicaidNC MEDICAID GROUP NUMBER
NC89132NKMedicaidDR FRAYNE INDIVIDUAL MCAI
NC018G2OtherNC BCBS GROUP NUMBER
NC1912985706OtherDANIEL FRAYNE NPI
NC1417943218OtherMICHAEL STHAY NPI
NC5903632MedicaidDR STHAY INDIVIDUAL MCAID
NC1417943218OtherMICHAEL STHAY NPI
NC2060594Medicare ID - Type UnspecifiedCIGNA MEDICARE
NC5903632MedicaidDR STHAY INDIVIDUAL MCAID
NC2003568AMedicare ID - Type UnspecifiedDANIEL FRAYNE CIGNA MEDIC
NC018G2OtherNC BCBS GROUP NUMBER
NCH69101Medicare UPINDR FRAYNE UPIN
NC5902144MedicaidNC MEDICAID GROUP NUMBER