Provider Demographics
NPI:1073073953
Name:CHARLES A CANNON JR MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:CHARLES A CANNON JR MEMORIAL HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VP MEDICAL STAFF RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ETTA
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-262-4133
Mailing Address - Street 1:155 FURMAN RD STE 202
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5049
Mailing Address - Country:US
Mailing Address - Phone:828-263-1211
Mailing Address - Fax:828-262-4103
Practice Address - Street 1:150 PARK AVE
Practice Address - Street 2:
Practice Address - City:BANNER ELK
Practice Address - State:NC
Practice Address - Zip Code:28604-6604
Practice Address - Country:US
Practice Address - Phone:828-898-5178
Practice Address - Fax:828-262-4103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health