NPIMap

Organization Active NPI

Watauga Medical Center, Inc.

Doing business as Watauga Medical Center

  • Psychiatry Physician
  • Boone, NC
National Provider Identifier
1407921802
Registry record updated Jan 15, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
WATAUGA MEDICAL CENTER, INC.
Doing business as
Watauga Medical Center
Practice address
336 Deerfield Rd
Boone, NC 28607-5008
Phone
(828) 262-9100
Fax
(828) 262-4157
NPI assigned
Nov 21, 2006
Last updated
Jan 15, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
APPALACHIAN REGIONAL HEALTHCARE SYSTEMAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 15, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Mary Etta Long, RHIA-CPMSM
Title
Sr VP Medical Staff Services
Phone
(828) 262-4133

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry Physician 2084P0800X NU Primary

Addresses

Primary practice location

336 Deerfield Rd
Boone, NC 28607-5008

Mailing address

155 Furman Rd
Suite 101
Boone, NC 28607-5049
Phone (828) 262-9100

Other identifiers 2

IdentifierTypeStateIssuer
8907630MedicaidNC
07630OtherNCBCBS PSY

Other names 1

  • Watauga Medical Center Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Cobius Healthcare Solutions

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040210000805 NC Part B Supplier - Clinic/Group Practice 2668377474 Receives reassigned benefits from 139 practitioners
6 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Boone, NC; Linville, NC; Jefferson, NC
O20060220000225 NC Part B Supplier - Clinic/Group Practice 2668377474 Receives reassigned benefits from 26 practitioners
Practice locations: Boone, NC

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

950 State Farm Rd
Boone, NC 28607
Phone (828) 263-8344

Practitioners & affiliated clinicians

Practitioners 64

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 64

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164067200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1736899200000",
    "number": "1407921802",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "155 FURMAN RD",
            "address_2": "SUITE 101",
            "city": "BOONE",
            "state": "NC",
            "postal_code": "286075049",
            "telephone_number": "828-262-9100",
            "fax_number": "828-262-4157"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "336 DEERFIELD RD",
            "city": "BOONE",
            "state": "NC",
            "postal_code": "286075008",
            "telephone_number": "828-262-9100",
            "fax_number": "828-262-4157"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WATAUGA MEDICAL CENTER, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "APPALACHIAN REGIONAL HEALTHCARE SYSTEM",
        "enumeration_date": "2006-11-21",
        "last_updated": "2025-01-15",
        "certification_date": "2025-01-15",
        "status": "A",
        "authorized_official_last_name": "LONG",
        "authorized_official_first_name": "MARY",
        "authorized_official_middle_name": "ETTA",
        "authorized_official_title_or_position": "SR VP MEDICAL STAFF SERVICES",
        "authorized_official_telephone_number": "828-262-4133",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "RHIA-CPMSM"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8907630",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS PSY",
            "identifier": "07630",
            "state": "NC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://cobiusconnect.cobius.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.1068.1",
            "affiliationName": "Cobius Healthcare Solutions",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "2720 Dundee Rd # 302",
            "city": "Northbrook",
            "state": "IL",
            "country_code": "US",
            "postal_code": "600622609",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Watauga Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Boone, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 15, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.