=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588698559
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHPARK BEHAVIORAL MEDICINE SPECIALISTS, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6845 FAIRVIEW RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-442-1655
-----------------------------------------------------
Fax | 704-442-9360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6845 FAIRVIEW RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-442-1655
-----------------------------------------------------
Fax | 704-442-9360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PATRICIA K BOYER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 704-442-1655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 9300426
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0805X
-----------------------------------------------------
Taxonomy Name | Geriatric Psychiatry Physician
-----------------------------------------------------
License Number | 9300426
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------