MEDICARE: DR. LAURA TAYLOR PRIDEMORE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	2001-01289	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598751513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA TAYLOR PRIDEMORE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:	704-384-7840
Fax Number	:	704-384-7830

Provider Business Practice Location Address
First Line	:	1994 WELLNESS BLVD STE 110
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28110-7768
Country	:	US
Telephone Number	:	704-384-8460
Fax Number	:	704-384-8465

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	06/20/2023

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