Basic Information
Provider Information | |||||||||
NPI: | 1811979339 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAYWOOD | ||||||||
FirstName: | TOMMIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 550 PEACHTREE ST NE | ||||||||
Address2: | SUITE 1600 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303082208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4048887575 | ||||||||
FaxNumber: | 4048857777 | ||||||||
Practice Location | |||||||||
Address1: | 2665 N DECATUR RD | ||||||||
Address2: | SUITE 350 | ||||||||
City: | DECATUR | ||||||||
State: | GA | ||||||||
PostalCode: | 300336149 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6785530226 | ||||||||
FaxNumber: | 6785530029 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2005 | ||||||||
LastUpdateDate: | 04/28/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 49420 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 640122796D | 05 | GA |   | MEDICAID |