Provider Demographics
NPI:1376611574
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: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:828-261-4133
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:828-737-7000
Mailing Address - Fax:828-737-7034
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:828-737-7000
Practice Address - Fax:828-737-7034
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APPALACHIAN REGIONAL HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-04
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0037275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5070877OtherUNITED HEALTHCARE SWINGBE
NC3461323Medicaid
NC152168200OtherOWCP SWB PROV NUMBER
NC0080COtherNC BLUE CROSS SWB PROV #
NC3461323Medicaid
NC0080COtherNC BLUE CROSS SWB PROV #