Provider Demographics
NPI:1225088255
Name:CHARLES A CANNON JR MEMORIAL HOSPITAL INC.
Entity Type:Organization
Organization Name:CHARLES A CANNON JR MEMORIAL HOSPITAL INC.
Other - Org Name:APPALACHIAN REGIONAL HEALTHCARE SYSTEM
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:
Authorized Official - Phone:828-262-4133
Mailing Address - Street 1:155 FURMAN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5049
Mailing Address - Country:US
Mailing Address - Phone:828-262-4111
Mailing Address - Fax:828-262-4157
Practice Address - Street 1:434 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:LINVILLE
Practice Address - State:NC
Practice Address - Zip Code:28646-0787
Practice Address - Country:US
Practice Address - Phone:828-262-4133
Practice Address - Fax:828-262-4103
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APPALACHIAN REGIONAL HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
NCH0037282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC152168200OtherOWCP ACUTE CARE PROV NUMB
TN0340005Medicaid
TN6065Medicaid
NC00103OtherNC BLUE CROSS ACUTE CARE
NC5070877OtherUNITED HEALTHCARE ACUTE #
NC3401323Medicaid
NC290780OtherMAMSI ACUTE CARE PROV NUM
NC3401323Medicaid
NC152168200OtherOWCP ACUTE CARE PROV NUMB