=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154371706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK G. HAYWOOD, MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2006
-----------------------------------------------------
Last Update Date | 04/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 WELLNESS WAY STE 210
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-442-1161
-----------------------------------------------------
Fax | 678-442-9967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 721 WELLNESS WAY STE 210
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-442-1161
-----------------------------------------------------
Fax | 678-442-9967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | DR. PATRICIA A HAYWOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-442-1161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 035898
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------