Provider Demographics
NPI:1316013733
Name:WATAUGA MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WATAUGA MEDICAL CENTER, INC.
Other - Org Name:WATAUGA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP MEDICAL STAFF SERVICES
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 1:155 FURMAN RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5049
Mailing Address - Country:US
Mailing Address - Phone:828-262-4133
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:828-262-4100
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:2006-11-28
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0077207P00000X, 208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0773GOtherEMERGENCY ROOM PHYSICIAN
NC890773GMedicaid
NC890773GMedicaid