Basic Information
| Provider Information | |||||||||
| NPI: | 1316013733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATAUGA MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | WATAUGA MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 FURMAN RD | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282624133 | ||||||||
| FaxNumber: | 8282624103 | ||||||||
| Practice Location | |||||||||
| Address1: | 336 DEERFIELD RD | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282624100 | ||||||||
| FaxNumber: | 8282624103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | ETTA | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP MEDICAL STAFF SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8282624133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | APPALACHIAN REGIONAL HEALTHCARE SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RHIA-CPMSM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | H0077 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | H0077 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | H0077 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0773G | 01 | NC | EMERGENCY ROOM PHYSICIAN | OTHER | 890773G | 05 | NC | MEDICAID |