Basic Information
| Provider Information | |||||||||
| NPI: | 1437541984 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES A. CANNON, JR. MEMORIAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OUTPATIENT LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 434 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | LINVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286460787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287377000 | ||||||||
| FaxNumber: | 8282624103 | ||||||||
| Practice Location | |||||||||
| Address1: | 434 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | LINVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286460787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287377000 | ||||||||
| FaxNumber: | 8282624103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2015 | ||||||||
| LastUpdateDate: | 02/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | ETTA | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP MEDICAL STAFF RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8282624133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | H0077 | NC | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.