Healthcare Provider Details

I. General information

NPI: 1245231364
Provider Name (Legal Business Name): HAYWOOD PEDIATRIC AND ADOLESCENT MEDICINE GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FACILITY DR
CLYDE NC
28721-9438
US

IV. Provider business mailing address

15 FACILITY DR
CLYDE NC
28721-9438
US

V. Phone/Fax

Practice location:
  • Phone: 828-452-2211
  • Fax: 828-452-4421
Mailing address:
  • Phone: 828-452-2211
  • Fax: 828-452-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRIS HENSON
Title or Position: BUSINESS MANAGER
Credential: CMA
Phone: 828-452-2211