Provider Demographics
NPI:1477006385
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:RHIA-CPMSM
Authorized Official - Phone:828-262-4133
Mailing Address - Street 1:434 HOSPITAL DRIVE
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:828-737-7713
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:828-737-7713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0037207RC0000X
207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty