Basic Information
Provider Information | |||||||||
NPI: | 1033548052 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WATAUGA MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | APPALACHIAN REGIONAL PAIN MANAGEMENT CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 336 DEERFIELD RD | ||||||||
Address2: |   | ||||||||
City: | BOONE | ||||||||
State: | NC | ||||||||
PostalCode: | 286075008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282624103 | ||||||||
FaxNumber: | 8282624103 | ||||||||
Practice Location | |||||||||
Address1: | 336 DEERFIELD RD | ||||||||
Address2: |   | ||||||||
City: | BOONE | ||||||||
State: | NC | ||||||||
PostalCode: | 286075008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282655493 | ||||||||
FaxNumber: | 8282661176 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2013 | ||||||||
LastUpdateDate: | 11/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONG | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | ETTA | ||||||||
AuthorizedOfficialTitleorPosition: | SR VP MEDICAL STAFF RELATIONS | ||||||||
AuthorizedOfficialTelephone: | 8282624133 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | APPALACHIAN REGIONAL HEALTH CARE SYSTEM | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RHIA-CPMSM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | H0077 | NC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.