Basic Information
| Provider Information | |||||||||
| NPI: | 1245231364 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAYWOOD PEDIATRIC AND ADOLESCENT MEDICINE GROUP, P.A. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HAYWOOD PEDIATRICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 FACILITY DR | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287219438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284522211 | ||||||||
| FaxNumber: | 8284524421 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 FACILITY DR | ||||||||
| Address2: | |||||||||
| City: | CLYDE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287219438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284522211 | ||||||||
| FaxNumber: | 8284524421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HENSON | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8284522211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CMA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01737 | 01 | NC | BCBS OF NC | OTHER | 8901737 | 05 | NC | MEDICAID |