1548335581 NPI number — WATAUGA MEDICAL CENTER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548335581 NPI number — WATAUGA MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATAUGA MEDICAL CENTER INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WATAUGA MEDICAL CENTER CRNA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548335581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 FURMAN RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BOONE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28607-5049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-262-4438
Provider Business Mailing Address Fax Number:
828-262-4157

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
336 DEERFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28607-5008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-262-4100
Provider Business Practice Location Address Fax Number:
828-262-4157
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ETTA
Authorized Official Title or Position:
SR VP MEDICAL STAFF RELATIONS
Authorized Official Telephone Number:
828-262-4133

Provider Taxonomy Codes

  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07630 . This is a "BCBS CRNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8907630 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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