Provider Demographics
NPI:1245231364
Name:HAYWOOD PEDIATRIC AND ADOLESCENT MEDICINE GROUP, P.A.
Entity Type:Organization
Organization Name:HAYWOOD PEDIATRIC AND ADOLESCENT MEDICINE GROUP, P.A.
Other - Org Name:HAYWOOD PEDIATRICS
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HENSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:828-452-2211
Mailing Address - Street 1:15 FACILITY DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-9438
Mailing Address - Country:US
Mailing Address - Phone:828-452-2211
Mailing Address - Fax:828-452-4421
Practice Address - Street 1:15 FACILITY DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-9438
Practice Address - Country:US
Practice Address - Phone:828-452-2211
Practice Address - Fax:828-452-4421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01737OtherBCBS OF NC
NC8901737Medicaid