Healthcare Provider Details

I. General information

NPI: 1699816017
Provider Name (Legal Business Name): LIYA BEYDERMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6115 PARK SOUTH DR STE 105
CHARLOTTE NC
28210-0104
US

IV. Provider business mailing address

215 N PINE ST UNIT 4403
CHARLOTTE NC
28202-2655
US

V. Phone/Fax

Practice location:
  • Phone: 704-981-6800
  • Fax: 704-944-8389
Mailing address:
  • Phone: 443-416-5539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number25MA08783500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number2017-01971
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number2017-01971
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: