Provider Demographics
NPI:1376611574
Name:CHARLES A CANNON JR MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:CHARLES A CANNON JR MEMORIAL HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP MEDICAL STAFF RELATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ETTA
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-261-4133
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:LINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28646-0787
Mailing Address - Country:US
Mailing Address - Phone:828-737-7000
Mailing Address - Fax:828-737-7034
Practice Address - Street 1:434 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:LINVILLE
Practice Address - State:NC
Practice Address - Zip Code:28646-0787
Practice Address - Country:US
Practice Address - Phone:828-737-7000
Practice Address - Fax:828-737-7034
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APPALACHIAN REGIONAL HEALTHCARE SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-04
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0037275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0080COtherNC BLUE CROSS SWB PROV #
NC3461323Medicaid
NC5070877OtherUNITED HEALTHCARE SWINGBE
NC152168200OtherOWCP SWB PROV NUMBER
NC3461323Medicaid
NC0080COtherNC BLUE CROSS SWB PROV #