Basic Information
Provider Information | |||||||||
NPI: | 1093107542 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WATAUGA MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OP IMAGING & LAB CENTER - WILMA REDMONT BREAST 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: | 8282624100 | ||||||||
FaxNumber: | 8282624103 | ||||||||
Practice Location | |||||||||
Address1: | 1200 STATE FARM RD | ||||||||
Address2: |   | ||||||||
City: | BOONE | ||||||||
State: | NC | ||||||||
PostalCode: | 286074994 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282662492 | ||||||||
FaxNumber: | 8282662488 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2015 | ||||||||
LastUpdateDate: | 05/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONG | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | ETTA | ||||||||
AuthorizedOfficialTitleorPosition: | SR VP MEDICAL STAFF RELATIONS | ||||||||
AuthorizedOfficialTelephone: | 8282624133 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 261QR0206X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 291U00000X | H0077 | NC | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.