Provider Demographics
NPI:1336215821
Name:WATAUGA MEDICAL CENTER INC
Entity Type:Organization
Organization Name:WATAUGA MEDICAL CENTER INC
Other - Org Name:WATAUGA MEDICAL CENTER EKG INT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP MEDICAL STAFF RELATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ETTA
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-262-4133
Mailing Address - Street 1:155 FURMAN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5049
Mailing Address - Country:US
Mailing Address - Phone:828-262-4438
Mailing Address - Fax:828-262-4157
Practice Address - Street 1:336 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5008
Practice Address - Country:US
Practice Address - Phone:828-262-4438
Practice Address - Fax:828-262-4157
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APPALACHIAN REGIONAL HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-27
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0077207RC0000X
208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC07630OtherBCBS EKG INT
NC8907630Medicaid
NC07630OtherBCBS EKG INT