Provider Demographics
NPI:1407006968
Name:CHARLES A CANNON JR MEMORIAL HOSPITAL INC
Entity Type:Organization
Organization Name:CHARLES A CANNON JR MEMORIAL HOSPITAL INC
Other - Org Name:CANNON INPATIENT BEHAVIORAL HEALTH
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:RHIA-CPMSM
Authorized Official - Phone:828-262-4133
Mailing Address - Street 1:155 FURMAN RD STE 101
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:828-262-9100
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:828-737-7000
Practice Address - Fax:828-737-7709
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APPALACHIAN REGIONAL HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-22
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NCH0037273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC021YEOtherBCBSNC
NC3401323SMedicaid
NC34-M323Medicare PIN