Provider Demographics
NPI:1588653489
Name:WATAUGA SURGICAL GROUP PA
Entity Type:Organization
Organization Name:WATAUGA SURGICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAGHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-264-2340
Mailing Address - Street 1:965 STATE FARM RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4948
Mailing Address - Country:US
Mailing Address - Phone:828-264-2340
Mailing Address - Fax:828-262-0731
Practice Address - Street 1:965 STATE FARM RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4948
Practice Address - Country:US
Practice Address - Phone:828-264-2340
Practice Address - Fax:828-262-0731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902879Medicaid
NC8902879Medicaid