Basic Information
| Provider Information | |||||||||
| NPI: | 1861031544 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATAUGA MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2600 | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286072600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282624133 | ||||||||
| FaxNumber: | 8282624103 | ||||||||
| Practice Location | |||||||||
| Address1: | 336 DEERFIELD RD | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282624133 | ||||||||
| FaxNumber: | 8282624103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2019 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | ETTA | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP MEDICAL STAFF RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8282624133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WATAUGA MEDICAL CENTER INC | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.