Healthcare Provider Details

I. General information

NPI: 1992761886
Provider Name (Legal Business Name): PRIME DOC OF HAYWOOD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 LEROY GEORGE DRIVE
CLYDE NC
28721-7430
US

IV. Provider business mailing address

5901-C PEACHTREE DUNWOODY ROAD SUITE 350
ATLANTA GA
30328-7159
US

V. Phone/Fax

Practice location:
  • Phone: 828-452-8862
  • Fax: 843-237-5073
Mailing address:
  • Phone: 678-441-8556
  • Fax: 678-441-8656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TALBOT G. MCCORMICK III
Title or Position: PRESIDENT
Credential: MD
Phone: 678-441-8500