Provider Demographics
NPI:1538220462
Name:CHARLES A CANNON JR MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:CHARLES A CANNON JR MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAYANNA
Authorized Official - Middle Name:MILLER
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-268-5522
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:2006-12-13
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0037314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3450005Medicaid
NC5070877OtherUNITED HEALTHCARE SNF #
NC0080FOtherNC BLUE CROSS SNF
NC152168200OtherOWCP SNF PROV NUMBER
NC3451323Medicaid
NC3405352Medicaid
NC3450005Medicaid
NC0080FOtherNC BLUE CROSS SNF