Provider Demographics
NPI:1346302783
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 SPECIALIST
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:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:LINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28646-0787
Mailing Address - Country:US
Mailing Address - Phone:828-737-7004
Mailing Address - Fax:828-262-9159
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:828-737-7004
Practice Address - Fax:828-262-9159
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APPALACHIAN REGIONAL HEALTHCARE SYSTEM INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-14
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
07744OtherBLUE CROSS
TN4280174OtherTN MEDICAID GRP PROV NUMB
NC8000300Medicaid
NC8000300Medicaid