Provider Demographics
NPI:1992761886
Name:PRIME DOC OF HAYWOOD, PA
Entity type:Organization
Organization Name:PRIME DOC OF HAYWOOD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TALBOT
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:678-441-8500
Mailing Address - Street 1:5901-C PEACHTREE DUNWOODY ROAD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-7159
Mailing Address - Country:US
Mailing Address - Phone:678-441-8556
Mailing Address - Fax:678-441-8656
Practice Address - Street 1:262 LEROY GEORGE DRIVE
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-7430
Practice Address - Country:US
Practice Address - Phone:828-452-8862
Practice Address - Fax:843-237-5073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC013PUOtherBLUE CROSS BLUE SHIELD
NCDC9720OtherRAILROAD MEDICARE
NC89013PUMedicaid
NCDC9720OtherRAILROAD MEDICARE